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Full text of "U.S. Navy Medicine Volume 69, Number 2 February 1978"

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February 15T/8 



VADM WHlard P. Aientzen, MC, USN 

Surgeon General of the Navy 

RADM R.G.W. Williams, Jr., MC, USN 

Deputy Surgeon General 

EDITOR 

Sylvia W. Shaffer 



ASSISTANT EDITOR 

Virginia M. Novinski 

EDITORIAL ASSISTANT 
Nancy R, Keesee 

CONTRIBUTING EDITORS 

Contributing Editor-in-Chief: 
CDR C.T. Cloutier (MC) 
Aerospace Medicine: CAPT M.G. Webb 
(MC); Dental Corps: CAPT R.D. Ulrey (DC); 
Education: CAPT S.J. Kreider (MC); Fleet 
Support: LCDR J.D. Schweitzer (MSC); 
Gastroenterology: CAPT D.O. Castell 
(MC); Hospital Corps: HMCM H.A. 
Olszak; Legal: LCDR R.E. Broach 
(JAGC); Marine Corps: CAPT D.R. Hauler 
(MC); Medical Service Corps: CDR R.L. 
Surface (MSC); Naval Reserve: CAPT J.N. 
Rizzi (MC, USN); Nephrology: CDR J.D. 
Wallin (MC); Nurse Corps: CAPT P.J. 
Elsass (NC); Occupational Medicine: CAPT 
G.M. Lawton (MC); Preventive Medicine: 
CAPT D.F. Hoeffler (MC); Psychiatry: 
CAPT S.J. Kreider (MC); Research: CAPT 
J. P. Bloom (MC); Submarine Medicine: 
CAPT J.C. Rivera (MC) 

POLICY; U.S. Nttvy Medicine is an official publication 
of the Navy Medical Department, published by the Bureau 
of Medicine and Surgery, It disseminates to Navy Medical 
Department personnel official and professional information 
relative to medicine, dentistry, and the allied health sci- 
ences. Opinions expressed are those of the authors and do 
not necessarily represent the official position of the Depart- 
ment of the Navy, the Bureau of Medicine and Surgery, or 
any other governmental department or agency. Trade 
names are used for identification only and do not represent 
an endorsement by the Department of the Navy or the Bu- 
reau of Medicine and Surgery. Although U.S. Navy Medi- 
cine may cite er extract from directives, official authority for 
action should be obtained from the cited reference. 

DISTRIBUTION; U.S. Navy Medicine is distributed to 
active-duty Medical Department personnel via the Standard 
Navy Distribution List. The follawuig distribution is author- 
ized: one copy for each Medical, Dental, Medical Service 
and Nurse Corps officer; one copy for every ID enlisted 
Medical Department members. Requests to increase or de- 
crease the number of allotted copies should be forwarded to 
U.S. Navy Medicine via the local command. 

CORRESPONDENCE: AH correspondence should be 
addressed to; Editor, U.S. Navy Medicine, Department of 
the Navy. Bureau of Medicine and Surgery (Code 0010), 
Washington, D.C. 20372. Telephone; (Area Code 202) 
254-4253, 254-4316, 254-4214; Autovon 294-4253, 294-4316. 
294-4214. Contributions from the field are welcome and will 
be published as space permits, subject to editing and pos- 
sible abridgment. 

The issuance of this publication is approved in accor- 
dance with Department of the Navy Publications and 
Printing Regulations (NAVEXOS P-35). 



NAVMED P-SOS8 



U.S.NAVY 




Volume 69, Number 2 
February 1978 



1 From the Surgeon General 

2 Department Rounds 

Health testing: now it's automated . . . Medical Department officers 
win AMSUS awards . . . The pack; new from Naval Ocean Systems 
Center 

5 BUMED SITREP 

6 Notes and Announcements 

Dental continuing education courses . . , Continuing education for 
Navy nurses . . . Correspondence course on communicable diseases 
in man . . . AFIP advanced forensic pathology course set for May 
. . . Fellowships available in infectious disease . . . Occupational 
safety and health grants available . . . American Academy of Family 
Physicians to meet . . . New members elected to American College 
of Hospital Administrators 

8 Features 

Preventive Medicine: Is It the Career for You? 
CAPTP.F.D. Van Peenen, MC, USN 

10 Navy Nurse Practitioners: Getting Our Act Together 
CDR A.L. O'Conneti, NC, USN 

12 Soundings 

The Necessity of Suffering 
LS. Baer, M.D. 

14 Education and Training Schools that train heroes 

16 Policy Instructions and directives 

17 NAVMED Newsmakers 

18 Professional 

The Anniversary Reaction: An Easily Overlooked 

Clinical Phenomenon 

CDR J.O. Cavenar, MC, USNR-R 

A. A. Mattbie, M.D. 

E.B. Hammett, M.D. 

22 Tooth-Supported Full Denture Prostheses: Review of the 
Literature and Patient Report 
LTG.E. Jeffers, DC, USN 

29 Scholars' Scuttlebutt 

Servicemen's and veterans group life insurance 

COVER: Through basic and advanced training. Navy hospital corpsmen 
learn to cope with medical problems that range from the bumps and 
bruises of dependent children to major injuries suffered by combat 
troops. An up-to-the-minute report of Hospital Corps School training 
begins on page 14. 



From the Surgeon General 



Occupational Health: 

A Must for Civilian Workers 



THE 1970s may be remembered as 
the Decade of Occupational Health. 
A recent flurry of federal legisla- 
tion, executive orders, and Navy in- 
structions gives evidence of national 
interest in combating workplace 
hazards that have potential for 
producing illness. At Navy activi- 
ties, potentially hazardous ionizing 
radiation, noise, asbestos, lead, 
mercury, solvents, welding, and a 
host of other toxic chemicals have 
been identified, and action has been 
taken to inform workers about these 
hazards and to provide protection. 

An important part of the Navy 
Occupational Health Program is 
protection of the 136,000 Navy civil- 
ian workers who support the fleet in 
shipyards, rework facilities, and in- 
numerable other industrial facilities 
in the U.S. and abroad. These men 
and women are included in the oc- 
cupational health programs man- 
dated to guarantee that, through 
sound preventive medicine meas- 
ures, active surveillance of all Navy 
workers is maintained. Monitoring 
may consist of physical examina- 
tions, chest X-rays, laboratory tests, 
bioassay to measure body burdens, 
audiometry, and measurement of 
specialized functions or body fluids. 

Industrial hygienists and indus- 
trial hygiene chemists survey the 
work environments of Navy installa- 
tions and, through on-site testing or 
analysis of collected air samples, 
determine if a particular toxic sub- 
stance is within safe levels per- 
mitted for an eight-hour day. After 




VADM Arentzen is welcomed aboard 
USS Orion (AS-18). 

such a study, recommendations are 
made for any needed corrective 
measures, which may include re- 
designing a work process, substitut- 
ing less toxic material for a chemical 
under scrutiny, isolating a particu- 
lar operation, installing exhaust 
ventilation, or even removing the 
work to another area. 

Of greatest importance is obtain- 
ing a complete occupational history 
that identifies the site of a worker's 
possible contact with potentially 
health-hazardous substances and 
determines the worker's compliance 



with or failure to follow safe work 
and health practices. Also identified 
in such a history are materials to 
which the worker may be uniquely 
sensitive. 

A skilled occupational health 
specialist— whether physician, hy- 
gienist, or nurse— can ferret out 
these incriminating toxins. Workers 
can then be helped to avoid further 
contact with them by controlling 
work practices that might lead to 
unwanted exposure to excessive 
levels of energies, or to injudicious 
or harmful inhalation, ingestion, or 
skin absorption of hostile environ- 
mental dusts, gases, vapors, and 
mists. 

Our civilian labor force helps 
keep our ships at sea, our airplanes 
in flight readiness, our vehicles roll- 
ing, and our Navy and Marine 
Corps installations and equipment 
at top efficiency. Through the occu- 
pational health services of our naval 
regional medical centers, our health 
care delivery extends beyond care 
of the sailor to reach these civilian 
workers, too. In fact, our civilian 
workers are second in priority only 
to active-duty personnel when seek- 
ing health care. From this kind of 
health outreach comes the human 
content of fleet support. 



M 




W.P. ARENTZEN 

Vice Admiral, Medical Corps 

United States Navy 



Volume 69, February 1978 



Department Rounds 




NNMC 



Health Testing: 
Now It's Automated 



Patient records her medical history on 
cathode ray tube 




Eye examinations test visual acuity and 
other eye (unctions 



Clinic appointment clerk schedules 
physical exams over telephone 



The Navy's automated multipha- 
sic health testing system was dedi- 
cated at the National Naval Medical 
Center, Bethesda, Md., on 16 Sept 
1977. A joint venture of the Navy 
and the Department of Defense Tri- 
Service Medical Information System 
(TRIMIS) Program, this is the first 
major clinic in a military medical 
facility designed specifically to ex- 
pedite physical examinations and 
provide valuable pre-admission 
medical information on patients en- 
tering the hospital. 

Planning for the AMHT Clinic 
began in 1973 when the problem of 
increasing requirements for medical 
care in the face of decreasing medi- 
cal manpower was becoming evi- 
dent, and computer technology was 
seen as one possible aid. 

The new clinic occupies 4,800 
square feet. Laboratory, X-ray, and 
other procedures required for a 
complete physical examination are 







Blood pressure is taken automatically 



Technician begins audiometry test 



2 



U.S. Navy Medicine 



centralized here, so patients no 
longer have to move from station to 
station within the medical center. 
Most examinations can be com- 
pleted within two hours, with the 
patient ready to go back to duty. 
The computer record provides 
quickly retrievable data that can be 
easily analyzed for treatment, reen- 
listment, change of duty, or hospital 
admission purposes. The informa- 
tion also provides a statistical base 
for planning. 

An individual who needs a physi- 
cal examination can make an ap- 
pointment by telephoning the clinic 
appointment clerk, who will im- 
mediately enter pertinent informa- 
tion about the individual into the 
computer. Later, when the patient 
reports to the clinic, the data al- 
ready stored in the computer will be 
confirmed. The patient will then be 
guided through a series of proce- 
dures by AMHT technicians thor- 
oughly trained in caring for people 
as individuals as well as in operat- 
ing machines that detect disease. 

Clinic procedures include a com- 
puterized medical history that the 
patient administers himself; an 
extensive hearing evaluation; a 
thorough eye examination, to in- 
clude a check for glaucoma; pulmo- 
nary function studies; an electro- 
cardiogram (with a computerized 
report available in about five min- 
utes); blood evaluation; and a com- 
plete blood count and urinalysis. 

By the time the physician or phy- 
sician's assistant is ready to ex- 
amine the patient, much of the in- 
formation needed to assist in the 
evaluation is available in a com- 
puter printout. Patients who have 
significant abnormal findings are 
referred to appropriate clinics and 
consultants. 

When fully operational, the new 
clinic will process approximately 80 
patients daily. If successful in sup- 
porting the Navy Medical Depart- 
ment mission, the prototype auto- 
mated multiphasic health testing 
system will be considered for instal- 
lation in other Navy medical centers 
as well as in Army and Air Force 
facilities. 



Four Win AMSUS Awards 



Four Navy Medical Department 
officers came home with awards 
from the 84th annual meeting of the 
Association of Military Surgeons of 
the U.S. (AMSUS), held in Wash- 
ington, D.C., 27 Nov-1 Dec 1977. 

CAPT Thomas J. Summerour 
(MSC), chief of the Pharmacy Ser- 
vice at Naval Regional Medical 
Center San Diego, received the 
Andrew Craigie Award for out- 
standing accomplishment in ad- 
vancing professional pharmacy 
within the federal government. 
CAPT Summerour was cited for 
significant contributions to federal 
pharmacy through outstanding 
leadership, innovative ideas, and 



CDR Sanborn's award consists of 
a bronze plaque and S500 honorar- 
ium. It was initiated by the Garrett 
Corp., and honors the memory of 
Major Gary Wratten, an Army phy- 
sician who died while testing medi- 
cal unit self-contained transportable 
hospital equipment under opera- 
tional conditions in Vietnam. 

LCDR Karen A. Reider (NC) of 
NRMC Oakland won the Federal 
Nursing Service Award for the best 
original essay advancing profes- 
sional nursing. LCDR Reider' s 
prize-winning essay, "Parents: The 
Unrecognized Victims of Child 
Abuse," will be published in Mili- 
tary Medicine. 




V 

(Left to right) CAPT Summerour, CDR Sanborn, LCDR Reider, LCDR Swanson 



support of hospital pharmacy resi- 
dency programs. 

The award, which consists of a 
silver plaque and S500 honorarium, 
honors Andrew Craigie, first Apoth- 
ecary General of the U.S., who 
served under General George 
Washington during the Revolution- 
ary War. It was established in 1959 
by Lederle Laboratories Division of 
American Cyanamid Co. 

The Major Gary Wratten Award 
for outstanding accomplishment in 
field military medicine went to CDR 
Warren R. Sanborn (MSC) of the 
Naval Health Research Center, San 
Diego. A specialist in public health 
and medical laboratory microbiol- 
ogy, CDR Sanborn was honored for 
innovative adaption of laboratory 
methods to technical operational 
field requirements, which "inesti- 
mably enhanced" the health of mili- 
tary personnel. 



The Federal Nursing Service 
Award consists of a scroll and $500 
honorarium. It is sponsored by 
Roche Laboratories Division, Hoff- 
man-LaRoche, Inc. 

The Federal Medical Resident's 
Award, given by AMSUS to an out- 
standing federal medical resident 
working in a federal hospital teach- 
ing program, was won by LCDR 
George C. Swanson (MC) for out- 
standing technical, academic, and 
research accomplishments while a 
resident in otolaryngology at NRMC 
Oakland. During his ENT residency, 
Dr. Swanson completed numerous 
projects, including research on 
noise protection devices, related 
audiology, and dermal grafts. He is 
now assigned to NRMC Guam. 

The Federal Medical Resident's 
Award consists of a plaque and $500 
honorarium, and is sponsored by 
the Purdue Frederick Co. 



Volume 69, February 1978 



3 



Research 



The Pack 



Transporting medical equipment 
and supplies from a ship's medical 
department to a shipboard casualty 
can be awkward and sometimes 
hazardous. Typically, the needed 
equipment and supplies are con- 
tained in a case about the size of a 
large fishing tackle box, which must 
be carried by hand. Oxygen aboard 
ship is contained in high-pressure 
cylinders often carried by their 
regulating valve — an extremely 
dangerous practice should the cylin- 
ders be damaged. Also, corpsmen 
and physicians who must carry this 
equipment to the scene of an 
emergency aboard ship find it diffi- 
cult to negotiate narrow passage- 
ways, ladders, hatches, and cat- 
walks. 

One possible solution: mount 
emergency equipment and supplies 
to a backpack frame. 

Under the sponsorship of the 
Naval Medical Research and Devel- 
opment Command, a two-pack sys- 
tem is being considered for devel- 
opment. One would be set up as a 
trauma pack useful in responding to 
all casualties aboard ship. Such a 
pack might contain one D oxygen 
cylinder, one surgical instrument 
and supply set, an Ambu bag, vari- 
ous splints, a blood pressure cuff, 
and intravenous supplies. 

The second pack would be used to 
assist cardiac arrest victims. It 
would contain an ECG monitor/defi- 
brillator, cardiac assist drugs, and 
oxygen. 

Both packs would feature remov- 
able modules to allow various com- 
binations of supplies to be carried. 
For example, special modules could 
be developed to treat burn victims, 
and modules that had been used 
could quickly be replaced by fully 
stocked units. 

A mockup of a trauma pack — 
dubbed Medipak — has been pro- 
duced by the Naval Ocean Systems 
Center, San Diego, and tested 
aboard USS Tripoli. This prototype 




FIGURE 1. HM3 R. Cipriano tests 
Medipak aboard USS Tripoli 

model (Figure 1) was built upon a 
modified frame available commer- 
cially. Also under consideration is 
the possibility of mounting the 
backpack on a Stokes litter (Figure 
2), thus providing a platform for the 
ECG monitor/defibrillator unit and 
oxygen while the patient is moved 
to the medical department. 

The compact Medipak can fit 
through an 18-inch hatch (Figure 3) 
and can be lowered between decks 
on a rope. A corpsman can climb 
through a 24-inch hatch while wear- 
ing it (Figure 4). 

Biomedical engineers at the Na- 
val Ocean Systems Center plan to 
fabricate other prototypes and carry 
out further tests and evaluations 
aboard ship. Ultimately, they will 
provide the Naval Medical Research 
and Development Command with 
recommendations on the feasibility 
of a medical backpack for shipboard 
use. 

Comments and suggestions re- 
garding the medical backpack con- 
cept and design are welcome. 
Write: Commanding Officer, Naval 
Ocean Systems Center, Attn: Code 
823, San Diego, Calif. 92152. 

— Story and photos contributed by Will T. 
Rasmussen, Ph.D., head. Biomedical Engi- 
neering Branch, Naval Ocean Systems Cen- 
ter. 




FIGURE 2. Medipak mounted on Stokes 
litter provides platform for ECG unit 




FIGURE 3. Medipak is lowered through 
18-inch hatch aboard USS Kitty Hawk 




FIGURE 4. HA White climbs through 
24-inch escape trunk with Medipak 



U.S. Navy Medicine 



BUMED SITREP 



NSHS BETHESDA ... The Naval 
School of Health Care Administration 
has a new name, a new commanding of- 
ficer, and an expanded mission. It's 
now known as the Naval School of 
Health Sciences, Bethesda, and is 
under the command of CDR William J. 
Auton (MSC). He will oversee the 
School's training programs for Medical 
Department members at the technical, 
undergraduate, graduate and postgrad- 
uate levels, as well as selected training 
for the Army, Air Force, and Coast 
Guard. 

In addition to the headquarters com- 
mand at Bethesda and numerous clini- 
cal training programs at the National 
Naval Medical Center, NSHS Bethesda 
is now responsible for administration of 
training detachments at the Naval Un- 
dersea Medical Institute, Groton, 
Conn.; the Naval School of Health 
Sciences, Portsmouth, Va.; and the 
Academy of Health Sciences, Fort Sam 
Houston, Tex. Also, "C" Schools at the 
National Naval Medical Center that 
were formerly under the Naval Health 
Sciences Education and Training Com- 
mand are now assigned to NSHS 
Bethesda for operations. 

The new role of NSHS Bethesda now 
includes clinical training for hospital 
corpsmen in direct patient care areas 
such as physical and occupational 
therapy, operating room technology, 
and nuclear and undersea medicine. 
Various diagnostic training programs in 
clinical laboratory procedures, electro- 
encephalography, and cardiopulmonary 
technology are also conducted. 

The School also sponsors baccalaure- 
ate programs in health care administra- 
tion — offered in cooperation with The 
George Washington University — execu- 
tive medicine programs, seminars for 
prospective commanding officers, and a 
Financial and supply management train- 
ing course. 

REVISED PUBLICATION ... The 

seventh revision of Medical Disposition 
and Physical Standards Notes, which 
contains considerable revised and new 
material, will be ready for distribution 
this month. Commanding officers and 
officers-in-charge of naval medical facil- 
ities should inform BUMED (Code 331) 
of the number of copies needed for their 
activity. 



AMA SUPPORT ... The American 
Medical Association has pledged its 
support of efforts to combat "continued 
attrition" in the ranks of military physi- 
cians. Under a resolution passed by the 
House of Delegates late in 1977, the 
AMA would confer with Congressional 
Armed Services Committees, the De- 
partment of Defense, and the Surgeons 
General to identify causes of such attri- 
tion and seek solutions to the problem. 
A progress report is to be made at the 
AMA annual meeting next June. 

BLOOD PROGRAM ... By regionaliz- 
ing its blood banks, the Navy is making 
better use of blood donated by sailors, 
Marines, and their families. The civilian 
community benefits, too, because effi- 
cient operation of Navy blood banks re- 
duces the demand on civilian sources. 

Since regionalization of Navy blood 
banks in 1973, the number of units of 
blood purchased from civilian sources 
has dropped from 7,000 to approxi- 
mately 600 units a year. Also, with more 
efficient collection and processing pro- 
cedures, the amount of blood that be- 
comes outdated before it can be trans- 
fused has dropped from 40% of units 
available to less than 10%. 

ADVANCEMENT . . . Navy men and 
women who attend "A" Schools will no 
longer be advanced to pay grade E-3 
automatically upon graduation. Effec- 
tive 1 Jan 1978, only those "A" School 
graduates who are fully qualified and 
who meet all requirements, including 
time-in-rate (six months as an E-2), will 
be advanced. 

This new policy has been adopted be- 
cause some people who received auto- 
matic advancements to E-3 subse- 
quently declined accelerated advance- 
ment to E-4 to preclude obligating 
themselves to a five-year commitment. 
At the same time, they used the "con- 
structive time" they acquired by early 
promotion to E-3 to go up for E-4 at a 
later date, without incurring an obliga- 
tion beyond their regular enlistment. 
This procedure was contrary to the in- 
tent of the program. 

After 1 January, "A" School gradu- 
ates who have served at a command for 
four to eight months and who are rec- 
ommended for accelerated advance- 



ment to E-4 may be advanced to that 
grade at the discretion of their new com- 
manding officer, even if they are not yet 
E-3*s. 

Details on this policy change are in 
revised BUPERS Notice 1430 of 1 Dec 
1977. 

AMSO PROGRAM ... A number of 
flight surgeon, aviation physiologist, 
and aviation experimental psychologist 
billets have been identified and as- 
signed to the Aeromedical Safety Offi- 
cer Program to assure continued direct 
aeromedical safety support to Navy and 
Marine Corps aviation commands. New 
BUMED Instruction 5100.11 of 14 Oct 
1977 sets forth the mission and function 
of the AMSO Program. 

AUDIT TD?S . . . Medical activities may 
wish to consider these recommenda- 
tions from recent audits: 

• Improve meal count procedures, as 
required by BUMEDINST 10110.2A and 
NAVSUP P-486, par. 2113. 

• Provide internal control and security 
over unissued meal passes, as required 
by BUMEDINST 10110.2A, section C, 
par. 6b and NAVSUP P-486, par. 
2112.4. 

• Establish a preventive maintenance 
program for food service equipment, as 
required by BUMEDINST 10110.2A, 
section 6, par. 4b. 

• Use compensatory time instead of 
overtime pay for civilian employees in 
the grades of GS-10 and above. 

• Review overtime authorization, and 
initial time and attendance cards certify- 
ing receipt of overtime authorizations, 
in accordance with NAVCOMPT Man- 
ual, par. 033002. 

• Carry out internal review of civilian 
payroll and timekeeping. 

MAIL TO HA WAD . . . Official mail 
continues to be misaddressed to discon- 
tinued FPOs in Hawaii. The result: de- 
layed mail. For official mail to Hawaii, 
the correct civil address lines and civil 
zip codes should be used. It's not 
enough to change just the zip code: in- 
stead, the entire Hawaii civil address 
line must be substituted for the FPO 
line. For example, mail addressed to 
CINCPACFLT should read: Commander 
in Chief, U.S. Pacific Fleet, Pearl 
Harbor, HI 96860. 



Volume 69, February 1978 



r. 



Notes & Announcements 



DENTAL CONTINUING EDUCATION COURSES 

The following dental continuing education courses 
will be offered in May 1978: 

National Naval Dental Center, Bethesda, Md. 

Periodontics 1-3 May 1978 

Dental auxiliary utilization 8-10 May 1978 

Management seminar 15-17 May 1978 



Eleventh Naval District, San Diego, Calif. 



Periodontics 



15-17 May 1978 



Letterman Army Medical Center, San Francisco, Calif. 
Oral surgery 1-4 May 1978 

Requests for courses administered by the Comman- 
dant, Eleventh Naval District, should be submitted to; 
Commandant, Eleventh Naval District (Code 37), San 
Diego, Calif. 92132. Applications for other dental con- 
tinuing education courses should be submitted to: Com- 
manding Officer, Naval Health Sciences Education and 
Training Command (Code 5), National Naval Medical 
Center, Bethesda, Md. 20014. Applications should ar- 
rive six weeks before the course begins. 

Cross-country travel and travel from outside the con- 
tinental U.S. to attend dental continuing education 
courses generally will not be approved due to funding 
limitations. 



CONTINUING EDUCATION FOR NAVY NURSES 

The Naval Health Sciences Education and Training 
Command will sponsor the following continuing educa- 
tion courses for Navy nurses: 

Oncology Nursing — Progress. Problems, and Prospects 
(18 contact hours) 
17-19 April 1978 NRMC Oakland, Calif. 

General staff nurses will learn new approaches to nursing care of 
oncological patients and their families. The changing and expanding 
concepts of therapy will be presented, with emphasis on the implica- 
tions for patient care. 

Critical Care of the Respiratory Patient (30 contact hours) 
24-28 April 1978 NRMC Great Lakes, 111. 

For critical care nurses with special interest in respiratory failure. 
The physiology of the respiratory and contributing systems will be 
considered, as well as mechanical and electrical equipment used to 
support and monitor these systems. Training in basic EKG interpre- 
tation is required for enrollment in this course. 

The courses are open to Nurse Corps officers not cur- 
rently assigned to an oversea billet. However, nurses 
assigned to Argentia, Newfoundland; Bermuda; Guan- 



tanamo Bay, Cuba; Keflavik, Iceland; and Roosevelt 
Roads, Puerto Rico, who have served at least six 
months on active duty may apply. The courses are also 
open on a space-available basis to Nurse Corps officers 
of the inactive Reserve. 

Nurse Corps officers wishing to attend these courses 
should apply to the Naval Health Sciences Education 
and Training Command (Code 7), National Naval Medi- 
cal Center, Bethesda, Md. 20014, following procedures 
set forth in the BUMED Instruction 1520.8 series. Ap- 
plications should be submitted several weeks before a 
course begins, 

CORRESPONDENCE COURSE ON 
COMMUNICABLE DISEASES IN MAN 

The Navy correspondence course, "Control of Com- 
municable Diseases in Man" (NAVEDTRA 10772-C), 
has been revised and is available to Medical Depart- 
ment officers, enlisted personnel on active duty, and 
Reservists in an inactive duty status. 

The new text, Control of Communicable Diseases in 
Man, 12th ed., American Public Health Association, 
1976, edited by Abram S. Benenson, provides the latest 
information on the control of communicable diseases. 
Each disease is identified by clinical nature and labora- 
tory diagnosis, and is differentiated from allied or re- 
lated diseases. Emphasis is placed on disease occur- 
rence, infectious agent, reservoir, mode of transmis- 
sion, susceptibility, resistance, and methods of control. 

The course consists of five assignments. Reservists 
must complete the course while in an inactive duty 
status in order to receive 10 retirement points. Person- 
nel who have completed earlier versions may receive 
additional credit toward retirement for completing the 
revised course. 

Requests for enrollment should be forwarded via offi- 
cial channels on form NAVEDTRA 1550/1 by changing 
the "to" line to read: Commanding Officer, Naval 
School of Health Sciences, Correspondence Courses 
Training, National Naval Medical Center, Bethesda, 
Md. 20014. 

ADVANCED FORENSIC PATHOLOGY 
COURSE SET FOR MAY 

The Armed Forces Institute of Pathology (AFIP) will 
offer an advanced forensic pathology course 1-5 May 
1978 at the FBI Academy in Quantico, Va. Topics to be 
covered include forensic immunohematology, ballistics, 
forensic photography, handling of physical evidence, 
investigations of homicide scenes, fingerprint examina- 
tions, hair and fiber examinations, presentation of find- 
ings in court, pathology of poisons, and patterns of 
injury. 



U.S. Navy Medicine 



Residents in forensic pathology, pathologists of the 
Armed Forces and federal service, and civilian patholo- 
gists are eligible to attend. This course is open only to 
people who have previously taken the AFIP basic foren- 
sic pathology course or who have equivalent experience 
in forensic pathology. All meals and lodging will be pro- 
vided at no cost to the participants. 

Applications are available from the Director, Armed 
Forces Institute of Pathology, ATTN: AFIP-EDZ, 
Washington, D.C. 20306. 



FELLOWSHIPS IN INFECTIOUS DISEASE 

The Infectious Diseases Division of the National 
Naval Medical Center Department of Medicine invites 
applications for fellowships in infectious disease. 

The two-year program will consist of clinical, labora- 
tory, and research experiences in all fields of infectious 
disease. Candidates may elect to emphasize tropical 
medicine, with part of their clinical training in a Navy 
overseas research laboratory. 

The program is part of the Uniformed Services Uni- 
versity of the Health Sciences, and meets requirements 
for the American Board of Internal Medicine examina- 
tion in infectious diseases. 

Candidates must have completed 36 months of post- 
graduate clinical training in internal medicine, and 
must be eligible for a commission in the Navy. For fur- 
ther information contact the Chairman, Department of 
Medicine, National Naval Medical Center, Bethesda, 
Md. 20014. 



OCCUPATIONAL SAFETY AND HEALTH 
GRANTS AVAILABLE 

The National Institute for Occupational Safety and 
Health (NIOSH) wants research and demonstration 
grant applications designed to promote occupational 
safety and health. Innovative approaches designed to 
define occupational safety and health problems and to 
recommend solutions, to understand and prevent occu- 
pational disease and accidents, and to eliminate or con- 
trol hazards are also welcome. 

Primary emphasis is placed on investigations related 
to cause and prevention of skin, neurologic, respira- 
tory, and musculoskeletal and back disorders; repro- 
ductive effects of occupational hazards; occupational 
safety; and control technology for occupational hazards. 
Other areas include, but are not restricted to, occupa- 
tional safety and health-related behavioral and motiva- 
tional factors, epidemiology, ergonomics, physiology, 
toxicology, pathology, effects of physical agents, head 
and body protection, biological and environmental 
sampling and analysis, and the development of physical 
and chemical analytical methods. 

Applications should be submitted on NIH Form 398 
to the Division of Research Grants, National Institutes 
of Health, Westwood Building, Bethesda, Md. 20014. 



For further information contact: C. liana Howarth, Re- 
search Grants Program Officer, National Institute for 
Occupational Safety and Health, Parklawn BIdg., Room 
8-63, 5600 Fishers Lane, Rockville, Md. 20857. Or tele- 
phone: (Area code 301) 443-4493. 

AMERICAN ACADEMY OF FAMILY 
PHYSICIANS TO MEET 

The fifth annual meeting of the Uniformed Services 
Chapter, American Academy of Family Physicians, will 
be held 11-14 April 1978 at the Jacksonville (Fla.) Hil- 
ton Hotel. 

The academic program has been approved for 18 
hours of continuing medical education credit by the 
American Academy of Family Physicians. Sessions will 
cover gastroenterology, dermatology, urinary tract in- 
fections, ophthalmology, sexual dysfunction, alcohol- 
ism, office orthopedics, and office management. A half 
day will be devoted to papers by military physicians, 
and another half day for chapter business. 

Registration fee is $30 for members of the Uniformed 
Services Chapter and $60 for nonmembers. Interested 
personnel should contact: ENS Michael R. McKenna, 
MSC, USN, Department of Family Practice, Naval Re- 
gional Medical Center, Jacksonville, Fla. 32214. 

MEMBERSHIPS IN AMERICAN COLLEGE, 
HOSPITAL ADMINISTRATORS 

The following Navy officers have been elected to 
membership in the American College of Hospital Ad- 
ministrators: 

CAPT J.C. Smout, MSC, USN 

CDR L.E. Angelo, MSC, USN 

CDR L.L. Biesiadny, MSC, USN 

CDR W.A. Godfrey, MSC, USN 

CDR J.E. Johns, MSC, USN 

CDR V.A. Swindall, MSC, USN 

LCDR F.F. Briand, MSC, USN 

LCDR W.M. Buckley, MSC, USN 

LCDR D.H. Fisher, MSC, USN 

LCDR L.V. Hilling, MSC, USN 

LCDR W.P. McGrath, MSC, USN 

LCDR H.H. Yates, MSC, USN 

LT C.W. Hagen, MSC, USN 

LT R.T. Howerton, MSC, USN 

LT R.S. Kayler, MSC, USN 

LT J. A. Kramer, MSC, USN 

LT C.C. Langston, Jr., MSC, USN 

LT D.J. Lemmerman, MSC, USN 

LT J.E. McBride, MSC, USN 

LT M.L. Mitchell, MSC, USN 

LT D. Suttle, MSC, USN 

LT G.A. Swales, MSC, USN 

LTJG H.C. Coffey, MSC, USN 

LTJG R.D. Harbaugh, MSC, USN 

LTJG C.J. Hooton, MSC, USN 

LTJG M.V. Weiner, MSC, USN 



Volume 69, February 1978 



Features 



Preventive Medicine: 
Is It the Career for You? 



CAPT P.F.D. Van Peenen, MC, USN 



Many Navy physicians finish the first year of gradu- 
ate medical education and an operational tour, or even 
specialty training in a clinical field, without deciding 
whether to remain in a strictly clinical practice. Some- 
times overlooked is a specialty rich in opportunity and 
professional satisfaction: preventive medicine. 

Both within military medicine and in the civilian 
world, career opportunities in preventive medicine are 
enticing. The demand for epidemiologists, occupational 
medicine physicians, and other preventive medicine 
specialists has never been greater. Academe, federal 
and local governments, research and industry all need 
such specialists. In addition, preventive medicine has 
shed its stereotype as a roost for unimaginative physi- 
cians who are not clinically oriented. 

Most schools of medicine — the Uniformed Services 
University of the Health Sciences (USUHS) among 
them — emphasize preventive medicine training for all 
students early in their curriculum. Team leaders for 
most of the large projects which will eventually dictate 
how medicine is practiced in this country are, more 
often than not, preventive medicine physicians. Finally, 
training in preventive medicine leading to board certifi- 
cation, including an academic year at an approved 
school of public health, is not overly long, nor is the 
payback time all that extensive. 

Although not obvious at first blush, many clinical 
decisions — and the majority of decisions with medical 
implications that are made by our Line colleagues — are 
based on sound epidemiological principles. Whether to 
immunize a female recruit against rubella, whether to 
order malaria prophylaxis for an entire Marine Corps 
battalion, whether to change outpatient clinic hours, 
whether to administer prophylactic antibiotics after 
surgery are but a few examples of the decisions with 
individual or community impact that are made every 
day. Unfortunately, such decisions can be based on a 
biased collection of data or worse, on biased interpreta- 
tion. This is where specialty training in preventive 
medicine pays off. 

Consider also that academic career opportunities now 
exist at the USUHS — the military medical school. A 
strong, tri- service staffed Department of Preventive 



CAPT Van Peenen is chairman. Department of Preventive Medi- 
cine and Biometrics, Uniformed Services University of the Health 
Sciences, Bethesda, Md. 20014. 



Medicine is a basic science department at the Univer- 
sity, and is headed by a military medical officer. Con- 
cerns of the Department of Preventive Medicine range 
from providing a solid curriculum for medical students 
to studying the epidemiology of diseases of military 
personnel and their families, to basic laboratory work in 
tropical diseases, to organizing a graduate program for 
physicians and allied scientists. 

Who should apply? 

Any graduate physician may apply for Navy-spon- 
sored training leading to board certification in general 
preventive medicine. Physicians already board eligible 
or qualified in other specialties may also wish to consid- 
er preventive medicine as a second career. Preference 
is given to physicians completing an operational tour 
and to physicians with excellent academic records. 

The director of preventive medicine at the Bureau of 
Medicine and Surgery (Code 55) and the Specialties 
Advisory Committee which reviews all requests for 
Navy-sponsored training in preventive medicine con- 
sider these factors in selecting residents: 

• academic record in medical school and the GME 
year. 

• motivation. 

• military record. 

A physician may apply for other residencies at the 




Exotic 



research under way in Southern Sudan 

U.S. Navy Medicine 



same time he or she applies for preventive medicine 
training; there is no reason, for example, that one can- 
not apply for, say, both family practice and preventive 
medicine residencies. 

How to apply? 

For training to start in 1979, applications with sup- 
porting documents should be submitted by 15 Aug 1978 
to the Commanding Officer, Naval Health Sciences 
Education and Training Command in accordance with 
BUMED Instruction 1520. 10G of 12 May 76. 

What land of training? 

The coming academic year will last from September 
1979 until June 1980. Successful applicants work 
toward a master's of public health at a civilian school of 
public health. Both school and curriculum must be ap- 
proved by the BUMED director of preventive medicine, 
who acts as ad hoc adviser to all Navy- sponsored physi- 
cians enrolled in the program. (Some schools and some 
curricula are more appropriate for military physicians 
than others.) 

Alternative programs approved by BUMED could in- 
clude placement in a program monitored by the USUHS 
Department of Preventive Medicine and conducted col- 
laboratively with the Walter Reed Army Institute of 
Research, with the physician reporting in July 1980 for 
a one-year residency. The Walter Reed program con- 
sists of a six-week didactic course in tropical medicine 
followed by a year of varied residency experience. 
Teaching opportunities during the residency are avail- 
able at the USUHS. Training in occupational and aero- 
space medicine can be adjusted to individual interests 
and monitored by the specialty advisers at BUMED. 

Payback time? 

A total of two years for both training years (M.P.H. 
plus the residency) is involved, so only two years are 
obligated after completion of the residency. 

Eligibility for board certification? 

Eligibility depends on previous education (time in 
clinical residencies may be applied). Physicians are 
eligible for board certification no later than three years 
following their residency, and usually sooner. Details 
should be discussed with BUMED's director of preven- 
tive medicine. 

Future assignments? 

These are determined principally by the BUMED 
director of preventive medicine in consultation with the 
physician being assigned. Assignments may include 
duty at Navy environmental and preventive medicine 
units in Hawaii, San Diego, Naples, or Norfolk. Other 
possibilities include research assignments at one of the 
naval medical research units in Jakarta, Cairo, or 
Taipei, at the USUHS, at the Navy Environmental 
Health Center, and many other assignments. 




Navy immunization programs fight back against disease 

But will the Navy support preventive medicine? 

It cannot do otherwise. The Navy Surgeon General is 
on record as supporting preventive medicine programs, 
as demonstrated by his letters on alcoholism, 
asbestosis, and smoking. And the USUHS is firmly 
committed to preventive medicine teaching and re- 
search. 

For answers to other questions or for further infor- 
mation, contact: 

CDR C.T. Cloutier, MC, USN 

Director, Medical Corps Programs 

Naval Health Sciences Education and Training Command 

Bethesda, Md. 20014 

Tel: Autovon 295-0684; (Area code 202) 295-0684 

CAPT Dennis F. Hoeffler, MC, USN 

Director, Occupational and Preventive Medicine Division 

Bureau of Medicine and Surgery (Code 55) 

Washington, D.C. 20372 

Tel: Autovon 294-4620; (Area code 202) 254-4620 

CAPT G.M. Lawton, MC, USN 

Deputy Director, Occupational and Preventive Medicine Division 

Bureau of Medicine and Surgery (Code 55-1) 

Washington, D.C. 20372 

Tel: Autovon 294-4620; (Area code 202) 254-4620 

CAPT M.G. Webb, Jr., MC, USN 

Division of Aerospace Medicine 

Bureau of Medicine and Surgery (Code 51) 

Washington, D.C. 20372 

Tel: Autovon 294-4361; (Area code 202) 254-4361 

CAPT Dirk Van Peenen. MC, USN 

Professor and Chairman. Dept. of Preventive Medicine 

Uniformed Services University of the Health Sciences 

4301 Jones Bridge Rd. 

Bethesda, Md. 20014 

Tel: Autovon 295-2237; (Area code 202) 295-2237 



Volume 69, February 1978 



Navy Nurse Practitioners: 



Getting Our Act Together 



CDR Anne L. O'Connell, NC, USN 



One can hardly read a newspaper 
or magazine without coming across 
an article about health care. Wheth- 
er the issue is who is going to deliv- 
er health care or who is going to pay 
for it, everyone seems to be getting 
in on the act. 

At Naval Regional Medical Cen- 
ter San Diego, the act in Navy nurse 
practitioner education is a duet star- 
ring the medical center and the Uni- 
versity of California, San Diego. 

HISTORY OF THE PROGRAM 

Faced with a shortage of general 
medical officers in 1973, RADM 
Herbert G. Stocklein (MC), then 
commanding officer of NRMC San 
Diego, appointed an ad hoc com- 
mittee to study the outpatient 
health care delivery system. Among 
the committee's recommendations 
was institution of a special program 
to educate nurses to deliver primary 
health care. 

In July 1973 just such a program 
was begun to prepare nine Nurse 
Corps officers to function as ambu- 
latory care nurse practitioners. 
Training lasted six months, and 
upon graduation the nine nurse 
practitioners were placed in various 
assignments within the medical 
center. 

After this initial effort, options for 
continuing what appeared to be a 
promising program were consid- 
ered. In an effort to place the pro- 
gram within the framework of an 
educational institution, the Univer- 
sity of California, San Diego, was 



CDR O'Connell is Navy co-director of the 
UCSD Primary Care Nurse Practitioner Pro- 
gram and supervisor of the family nurse 
practitioner specialty component at the Naval 
Regional Medical Center, San Diego, Calif. 
92134. 



approached to explore the feasibility 
of extending the program under the 
auspices of the University. There 
was great interest within the De- 
partment of Continuing Education, 
and a memorandum of understand- 
ing was subsequently written to 
establish a program that would 
award a nurse practitioner certifi- 
cate and continuing education credit 
to each graduate. The program 
gained official Bureau of Medicine 
and Surgery sponsorship in May 
1974. During the past year the pro- 
gram has been transferred to the 
School of Medicine, University of 
California, San Diego, so graduates 
receive both a nurse practitioner 
certificate and upper division aca- 
demic credit transferrable to other 
institutions of higher education. 

WHERE WE ARE NOW 

Just as any longstanding produc- 
tion requires good criticism to im- 




LCDR Hoi man checks for ear infection 




CDR O'Connell (right) supervises stu- 
dents during fundoscopic examination 




PI 



Mm 



Students learn use of ophthalmoscope 



10 



U.S. Navy Medicine 



prove and an occasional change in 
the cast, so too, our joint act is un- 
der constant surveillance from both 
starring performers to assure the 
latest and best in nurse practitioner 
education. 

The training program, which now 
lasts one year, is designed to edu- 
cate civilian registered nurses and 
Navy Nurse Corps officers to prac- 
tice in expanded nursing roles. It 
offers three areas of specialization: 
family practice, obstetrics and gyn- 
ecology, and pediatrics. During the 
first two quarters, the required core 
curriculum includes a review of 
anatomy and physiology, cell biol- 
ogy, history-taking, interviewing, 
physical examination, psychosocial 
assessment, problem-solving tech- 
niques, and adaptation to the ex- 
panded role. The third and fourth 
quarters are devoted to clinical 
practice (preceptorship) in the stu- 
dent's specialty area, augmented by 
seminars and continuing didactic 
classes. Among the facilities used, 
in addition to NRMC San Diego and 
its regional clinics, are the Univer- 
sity hospital and clinics, Kaiser 
Permanente Medical Group, San 
Diego State University Student 
Health Services, and several com- 
munity clinics and private physi- 
cians' offices. 

The primary goal is to graduate 
nurses who can make a broad con- 
tribution to patient care. By gaining 
the additional tools of history tak- 
ing, physical examination, and as- 
sessment — tools for many years 
thought to be the sole prerogative of 
the physician — nurse practitioners 
can help build a trusting, productive 
relationship between health care 
provider and patient. As it is often 
easier for patients to present them- 
selves for cure rather than care, it is 
the person who initially deals with 
their physical complaints who will 
be most effective in helping patients 
deal with the psychosocial and edu- 
cational aspects of health care. For 
this reason, nurses have been more 
successful helping patients manage 
their health problems when they, as 
nurse practitioners, make the initial 
contacts. The effect of eliciting a 



detailed history and performing a 
thorough physical examination can 
never be underestimated in the 
long-term therapeutic nurse practi- 
tioner-patient relationship; it should 
be viewed as the basic building 
block for all health management 
and teaching to follow. 

AFTER GRADUATION 

Within the Navy health care sys- 
tem today, nurse practitioners are 
functioning in many areas, from 
pediatric and internal medicine 
clinics to family practice and Ob/ 
Gyn settings. A recent survey of 27 
Navy family nurse practitioners 
showed that most were satisfied 
with their new expanded role. By 
far the greatest satisfaction came 
from patient acceptance of the 
nurse as primary health care pro- 
vider. Many nurses welcomed the 
opportunity to practice in a health- 
oriented rather than illness-oriented 
framework; also, most of the nurses 
felt great satisfaction from their re- 
lationship as colleagues with other 
health professionals — physicians, 
nurses, and paraprofessional per- 
sonnel. 

It would be naive to say there are 
no problems. The tendency to place 
the nurse practitioner in a medical 
rather than a nursing model has led 
to some frustration. Effective nurs- 
ing takes time: many nurse practi- 
tioners have had to educate and re- 
educate administrators on the im- 
portance of a time framework that 
will meet the needs of both the insti- 
tution and the nurse practitioner. 
Additionally, there are billet con- 
straints limiting the number of 
nurses who can be educated for the 
expanded role of nurse practitioner 
and the facilities to which they can 
be assigned upon graduation. Iden- 
tifying these and other problems 
has helped the Navy focus attention 
in its continuing endeavor to evalu- 
ate and improve the utilization of its 
nurse practitioners. 

By far, the satisfactions of this 
expanded role outweigh the frustra- 
tions. By adopting and integrating 
traditionally medical tasks into our 



nursing practice, we are narrowing 
the gap between ourselves and the 
patient — a distance we have been 
trying to overcome for years. 

Some days we feel that our act is 
still on the road and hasn't yet made 
the Broadway big time. Often, on 
just this type of day, our patients 
respond to our nursing skills with, 
"It's nice to have someone who 
listens" or "No one ever explained 
that to me before." That's when we 
realize how important and satisfy- 
ing our new role is. 




Reflex check is part of physical exam 
WHO MAY APPLY? 

The Navy Nurse Corps, with its 
educational program and support of 
nurse practitioners in the expanded 
role, is helping lead the way for the 
expansion of nursing in primary 
health care. Applicants for the 
nurse practitioner programs should 
be Nurse Corps officers who have 
had a minimum of three years of 
diversified experience (at least one 
year in the desired area of specialty) 
and are motivated towards a Navy 
career. Applicants must be mature 
and responsible; they must have 
knowledge of their own behavior 
and attitudes towards patients in 
a therapeutic situation, or be willing 
to explore their own behavior and 
attitudes. The pioneers in the ex- 
panded role of Navy nursing must 
be qualified for leadership posi- 
tions, since the definition and im- 
plementation of the new role will 
largely be their responsibility when 
they begin to practice in Navy 
health care settings. 



Volume 69, February 1978 



11 



Soundings 



'Bibliotherapy' helps patients understand . . . 

The Necessity of 
Suffering 

Louis Shattuck Baer, M.D. 



Forty years of practicing medicine, 30 as a family 
physician, have taught me that often the precepts of 
philosophy surpass medicine or surgery as therapy for 
patients. It is not that physicians attempt to carry phi- 
losophy over into medicine; rather, as Victor Frankl 
observed, "Patients are constantly presenting us with 
philosophic problems" (1). 

Please note this short article is about the necessity of 
suffering, not the inevitability of suffering. It is my 
thesis that suffering is as necessary as oxygen, nitrogen 
or carbon for man's origin, evolution and survival. 

I believe that the mechanistic evolution of mankind 
through genetic mutation and natural selection pre- 
supposes at least 300 million years of conscious suffer- 
ing by sentient creatures. Surely Loren Eisley was 
thinking of the evolutionary necessity of suffering 
when, in The Immense Journey, he described his feel- 
ings on finding a pre-human skull, perhaps ten million 
years old, at the bottom of a deep, narrow crack in some 
sandstone. He contemplates this fossil skull, and then 
the cunning manipulability of his own Fingers, and 
records his thoughts in these words: 



Think of the way we came and be a little proud! Think of this 
hand — the utter pain of its first venture on the pebbly shore. 

Robert Ardrey, too, in African Genesis, alludes to the 
suffering of our arboreal ancestors forced to become 
terrestial by the terrible ten- million-year drought that 
converted Miocene forests into the bush and grasslands 
of the Pliocene Age. Ardrey writes: 

We are bad weather animals, disaster's children .... For the 
soundest of evolutionary reasons we appear at our best when times 
are worst. 

That is, when we suffer. 



Dr. Baer is emeritus clinical professor of medicine, Stanford Uni- 
versity School of Medicine. His office is at 411 Primrose Rd., Burlin- 
game, Calif. 94010. Dr. Baer served in the Navy Medical Corps 
during World War II, and was a contributor to the U.S. Naval Medical 
Bulletin, a forerunner of U.S. Navy Medicine. 



One final word on the evolutionary necessity of suf- 
fering. Though man is the latest of the primates, I am 
sure he is not the last. Our suffering as a species is 
necessary to mold by natural selection and genetic 
mutation the improved primate who will walk this earth 
in ages to come. I cast my vote with those who believe 
in the improvement of Homo sapiens through suffering. 

NECESSITY FOR ACQUIESCENCE 

The Book of Job, written by a Hebrew scholar and 
poet about 450 B.C., is the only part of the Old Testa- 
ment which deals reflectively with the problem of suf- 
fering. Throughout the rest of the Old Testament there 
is little questioning — only the statement that disobedi- 
ence to the law of God results in punishment, suffering 
and misery. From the standpoint of philosophic ther- 
apy, this belief is valueless. 

There are, however, two parts of the Book of Job that 
I have prescribed as "bibliotherapy" for the patient 
who asks me, "Why must I suffer?" 

The first is Chapter 2, verses 9-10, in which Satan is 
given permission to "touch Job in his bone and flesh." 
We see Job tormented, sitting among ashes, scratching 
his boil-covered skin with a potsherd. Here the poet 
anticipates by 2,500 years Jacobi and Jung in their feel- 
ing that "suffering is not an illness; it is the necessary 
counterpole to happiness" (2). 

Chapters 38 through 42, in the second part of the 
Book of Job, also may be helpful for the patient who 
questions the why of suffering. These are magnificent 
and dignified passages whose poetry and thought have 
never been surpassed. Job remembers his past health 
and strength, cites his present sorrows and miseries, 
and questions the reasons for his suffering. The re- 
sponse begins with the familiar lines: "Then the Lord 
answered Job out of the whirlwind: 'Who is this that 
darkeneth counsel by words without knowledge?'" 

In the following five inspired chapters, the Hebrew 
poet says what Albert Schweitzer thousands of years 
later summarized so brilliantly: 

All thinking must renounce the attempt to explain the Universe. 
. . . The Spirit of the Universe creates while it destroys and de- 
stroys while it creates. ... It remains to us a riddle. The first active 
deed of thinking is resignation — acquiescence in what happens (3). 

PATIENT REPORT 

A 58-year-old lawyer, who has been my patient for 25 
years and whom I have known since our undergraduate 
days in 1931, helps illustrate Nietzsche's statement that 
' 'the fleetest beast to bear you to perfection is suffer- 
ing" (4). For a score of years, this lawyer was superla- 
tively successful academically, professionally, finan- 
cially and socially. By 1951 he was the most arrogant, 
offensive man I knew. 

Then Clotho, the Goddess of Fate, who spins the 
thread of life, nudged his car on the freeway. The acci- 



12 



U.S. Navy Medicine 



dent so badly ' damaged his cervical spinal cord that 
since then he has been able to walk only short dis- 
tances, slowly, on level ground, and with the aid of two 
crutches. His arms are so weak and his fingers so awk- 
ward that his wife has to help him with his bathroom 
needs and in getting dressed. He must rest supine 16 
hours a day. 

He had to give up trial law, and took a job doing legal 
research for a local law firm, at a greatly reduced 
income. 

For the first three years after his accident he was in 
despair and often suicidal. He had frustrating sexual 
problems, severe financial problems, and a battalion of 
humiliating trials as a result of his crippled state. As 
treatment, I provided chiefly hope, friendship, and 
bibliotherapy. When I made my house calls, I would 
bring him books from our public library — works of his- 
tory, biography and philosophy that I enjoyed studying; 
works of playwrights and novelists that 1 enjoyed for 
recreation. 

This man's metamorphosis has been as complete as 
any in the world of zoology, though it took nearly ten 
years. Today he is kind, patient, tolerate and compas- 
sionate — qualities for which he previously was not 
greatly noted. 

While we were both enjoying some after-dinner 
claret last year, I told my friend I thought he illustrated 
Thackeray's thesis: "There are a great number of ex- 
cellences which might never come into existence had 
not sorrow or misfortune engendered them" (5). 

My friend replied by taking down from his library 
shelf two books. In The Chosen, by Chaim Potik, he 
showed me where he had doubly underlined the sen- 
tence, "Suffering has meaning only if we give it mean- 
ing." On the inside cover of George Eliot's Adam Bede, 
he had copied the author's statement: "Deep unspeak- 
able suffering may well be called a baptism, a regen- 
eration . . . doubtless a great anguish may do the work 
of years." He had copied these words in red ink when 
his handwriting was still nearly illegible as a result of 
his injuries. 

He told me that two quotations I had given him had 
helped him in the struggle to get back on his feet. From 
his wallet he withdrew an old, faded, folded prescrip- 
tion blank. On it, 25 years earlier, I had printed: 

That which does not kill me makes me stronger. 

Friedrick Nietzsche 
Thus Spake Zarathustra 

Misfortune is a good breast for the nourishment of great souls. 

Victor Hugo 
Les Miserables 

PHILOSOPHIC NECESSITY 

A patient afflicted with a severe, or chronic, or 
progressive illness will sometimes ask, "Why must I 
suffer?" He is, of course, seeking the philosophical 



rather than the physiological answer. If we are unable 
medically to relieve his suffering, we must try, as 
Kazantzakis said, "to change the eyes with which he 
sees the reality of his suffering" (6). This is particularly 
important in caring for patients whose strength or faith 
has been weakened by a long and serious illness, for 
these are the patients who most need philosophic ther- 
apy. 

As a family doctor, I believe it is the physician's re- 
sponsibility to relieve or diminish his patient's 
suffering. But it is the physician's duty, when indi- 
cated, to show the patient the necessity of suffering. 

Many of my patients have found these reflections 
helpful: 

That there is suffering in this world needs no supporting argu- 
ments. We have reason to believe that, although we may hope for a 
better, we need not look for a perfect world, either in the near or 
distant future ... for it is imperfect of necessity .... Existence 
involves diversity and movement and thus better and worse! .... 
To ask that these differences should be eliminated is to ask that the 
universe and we with it should pass away. 

The discords (mighty opposites) are a factor in the scheme . . . 
they are a necessary condition of existence .... Existence is there- 
fore of necessity oxymel, i.e., bittersweet. 



From the fountain of life, from the slow sweet hours that bring 
us all things good, from the slow sad hours that bring us all things 
ill . . . are derived al! our possessions, all the wealth and substance, 
all subjects and all qualities, all that makes us what we are (7). 

Let us be thankful that our sorrows live on in us as an indestruct- 
ible force, only changing their form, as forces do, and passing from 
pain into sympathy and understanding (8). 

It is only through his ability to reflect and act upon his suffering 
that a man is able to rise above himself .... When you have wet 
the earth with your tears to the depth of a foot, then you will take 
joy in everything (9). 

Without the suffering that our race has endured for 
the past 20 milleniums, human beings would perish 
from the earth and be replaced by a nonreflective 
anthropoid primate. In a word, a world without suffer- 
ing would become a world without man. 

REFERENCES 

1. Frank! V: Man's Search for Meaning. Boston: Beacon Press, 
1962. 

2. Jacobi J (ed): Writing of C.G. Jung. New York: Pantheon 
Books Inc., 1953. 

3. Schweitzer A: Out of My Life and Thought. New York: Holt 
Rinehart &. Winston, 1949. 

4. Neitzsche F: Thus Spake Zarathustra. New York: Modern Li- 
brary, 1954. 

5. Thackeray WM: Pendennis. London: Smith Elder & Co., 1876. 

6. Kazantzakis N: The Fratricides. New York: Simon & Schuster, 
1963. 

7. Dixon WM: The Human Situation. New York: Oxford Univer- 
sity Press, 1967. 

8. Eliot G: Adam Bede. London: Collins, 1859. 

9. Camus A: The Myth of Sisyphus. New York: Vintage Books, 
1955. 



Volume 69, February 1978 



13 



Education fi Training 

Schools That Train Heroes 



In terms of appearance, "Doc" 
Jackson wasn't much to write home 
about that day back in 1968. 
Slumped on his bunk in a pair of 
dirty jungle greens, he looked 
something like a laundry bag full of 
loose socks. But Jackson was a Navy 
hospital corps man who had done 
something extraordinary: during 
the past day and a half in the field, 
with nothing more than his medical 
first-aid kit and sheer determination 
to help him, he had saved the lives 
of four Korean Marines who had 
stumbled onto a land mine and were 
bleeding profusely when he reached 
them. 

Back in his neat dispensary, 
physically and mentally exhausted 
after the experience, Jackson 
passed it off as doing the job for 
which he had been trained. 

Leroy Jackson was among hun- 
dreds of Navy hospital corpsmen 
who found themselves in odd, often 
isolated locations in South Vietnam. 
The dedication and professionalism 
they and their Army and Air Force 
counterparts demonstrated as para- 
medics in that war saved thousands 
of lives. 

They were the men at the begin- 
ning of a long but remarkably effi- 
cient medical pipeline which 
reached from the battlefield to the 
finest medical facilities in the U.S. 
It was a system of health care de- 
livery made possible by the skill and 
devotion of the "Docs," the versa- 
tility of helicopters, and the speed 
of jet aircraft. 

Basics. How does the Navy equip 
a hospital corps man to cope with 
medical problems that range from 
the bumps and bruises of depend- 
ent children to major injuries suf- 
fered by combat troops? 

CDR Gene L. Hammett (MSC), 
executive officer of the Naval School 
of Health Sciences, San Diego, ex- 



plains the broad concept that pro- 
duces Navy hospital corpsmen. 
"The process begins in basic recruit 
training," CDR Hammett says. "A 
few individuals are selected after 
spending time in the fleet, but the 
majority of candidates come directly 
from recruit training. They are care- 
fully screened and tested and must 
meet rigid personality standards 
before they are accepted. Most are 
high-school graduates with good 
academic records, and all must have 
a desire to work with people." 

Navy hospital corpsmen begin 
their careers by attending Basic 
Hospital Corps School at either San 
Diego or Great Lakes, 111. This ten- 
week training offers students 400 
hours of instruction — 344 hours of 
didactic training and 56 hours of 
practical and laboratory experience. 

The Basic Hospital Corps School 
curriculum covers anatomy and 
physiology, patient care and ward 
experience, environmental health, 
drug therapy, mathematics, and 
administrative and military proce- 
dures. The largest block of time — 
102 academic and 36 practical ex- 
perience hours — is dedicated to pa- 
tient care. Students study team care 
concepts and nursing procedures 
for surgically and medically ill pa- 
tients, and become familiar with 
medical terminology. 

Another 70 hours of instruction 
are devoted to emergency medical 
treatment. Students are taught the 
principles of providing emergency 
care under a variety of circum- 
stances — from cardiopulmonary re- 
suscitation to emergency childbirth. 

Direction. "The school gives men 
and women the basic knowledge 
they will need to function compe- 
tently as medical assistants," CDR 
Hammett says. "When they com- 
plete Basic Hospital Corps School, 
they are qualified to fill a broad 



spectrum of jobs with the operating 
forces or at shore facilities. ' ' 

Graduates also receive a certifi- 
cate from the Department of Trans- 
portation certifying that they have 
completed the educational require- 
ments for Emergency Medical 
Technician Level I. 

At the Naval School of Health 
Sciences, San Diego, the faculty is 
made up of 26 officers and 91 senior 
enlisted men and women. The offi- 
cers include one physician, 17 
nurses, and eight Medical Service 
Corps members. In addition to the 
Basic Hospital Corps School, the 
faculty has academic responsibility 
for 11 advanced training programs. 
The faculty at Great Lakes, respon- 
sible for the Basic Hospital Corps 
School, consists of 14 officers and 17 
enlisted members. Both faculties 
have a cadre of support personnel. 

"Here at San Diego, we graduate 
about 2,500 men and women from 
the Basic Hospital Corps School 
each year," CDR Hammett reports. 
"That's approximately 50 students 
a week for 50 weeks. The school at 
Great Lakes graduates a similar 
number of students. 

"It isn't an easy school to com- 
plete. About 10% of Basic Hospital 
Corps School students are lost for a 
variety of reasons, including aca- 
demic failure, lack of motivation, 
and in a few cases disciplinary prob- 
lems. But on the whole, both 
schools have a good success aver- 
age." 

After this basic education, the 
direction a hospital corpsman's 
career takes usually depends on his 
or her interest and talent. "Most 
graduates of the Basic Hospital 
Corps School go directly to billets 
ashore or afloat where they gain ex- 
perience working with patients," 
CDR Hammett says. "Occasionally 
previous experience or unique qual- 
ifications allow a graduate to im- 
mediately enter advanced training 
in a specialized discipline." 

Advanced school. After complet- 
ing Basic Hospital Corps training 
and serving approximately one year 
in the field, a hospital corpsman can 
apply for advanced training. These 



14 



U.S. Navy Medicine 



advanced schools are known as "C" 
Schools. The Naval School of Health 
Sciences, San Diego, hosts 11 
advanced programs: pharmacy, 
cardiopulmonary, medical labora- 
tory, cytotechnology, ocular, op- 
erating room, otolaryngology, urol- 
ogy, X-ray, clinical nuclear medi- 
cine, and advanced hospital corps- 
man. Advanced programs are also 
located at the Naval School of 
Health Sciences, Portsmouth, Va.; 
Naval Aerospace Medical Institute, 
Pensacola, Fla.; Naval Undersea 
Medical Institute, New London, 
Conn.; Naval Regional Medical 
Center, Oakland, Calif.; and several 
other sites. Army, Air Force and 




Students learn the fine points of patient 
care from LT Gearhart (NC) 

Coast Guard students, as well as 
Navy members, attend these ad- 
vanced schools. 

Of the 1 1 advanced programs of- 
fered at San Diego, one of the most 
demanding is the 40-week course of 
instruction for men and women des- 
tined to become advanced hospital 
corpsman technicians (formerly 
called independent duty techni- 
cians). 

Two hundred and fifty candidates 
are selected each year for Advanced 
Hospital Corpsman Technician 
School. Five classes, each with 25 
students, convene each year at San 
Diego and Portsmouth. Standards 
for prospective students are rigid: 
only senior petty officers are ac- 
cepted and competition for entrance 
is keen. 



"Everyone is screened for inter- 
est, maturity, experience, and past 
performance," CDR Hammett says. 
"The attrition rate is minimal." 

"The school is designed to give 
students knowledge in breadth rath- 
er than depth, although each area is 
thoroughly covered," he explains. 
"Corpsmen who complete Ad- 
vanced Hospital Corpsman Techni- 
cian School are qualified to serve as 
paramedics in the truest sense of 
the word. I know of no comparable 
course of study in the civilian medi- 
cal sector." 

Independent. CDR Hammett 
points out that advanced hospital 
corpsman technicians aren't physi- 
cian surrogates. "They are trained 
to handle most medical situations 
independently, with the advice and 
consent of physicians if at all possi- 
ble," he says. "But by the very 
nature of the Navy's mission, the 
advanced hospital corpsman tech- 
nician on independent duty must be 
able to handle both routine and 
emergency problems with little or 
no outside help." 

CDR Hammett explains that with 
some 450 ships in the fleet, it's im- 
possible for each one to carry a 
medical officer. As of 31 Oct 1977, 
there were 1,115 billets afloat and 
ashore requiring the assignment of 
advanced hospital corpsman tech- 
nicians. On ships with small crews 
and at overseas shore stations 
where a physician is not assigned, 
the advanced hospital corpsman 
technician must provide for the 
medical needs of the crew — render- 
ing treatment which is within his 
capability and, when possible, aero- 
medically evacuating patients who 
need the skills of a physician and 
the facilities of a hospital. 

Candidates for the advanced hos- 
pital corpsman technician designa- 
tion spend a total of 1,600 hours in 
didactic and practical training. The 
largest single block of instruction is 
devoted to management of medical 
and surgical situations; in these 
classes, students are introduced to 
diseases and traumatic conditions 
they can expect to encounter as ad- 
vanced hospital corpsman techni- 



cians. Another 88 hours are spent in 
laboratories where students apply 
the knowledge they've gained in the 
classroom. 

Emphasis is also given to preven- 
tive medicine and environmental 
health. In 193 hours of training, 
students learn principles of food 
and water sanitation, vector and 
communicable disease control, pre- 
ventive dentistry, and control of in- 
dustrial chemicals and materials 
hazardous to individuals and the 
environment. Other areas covered 
include administration of health 
education programs, Medical De- 
partment management, medical 
sciences, and clinical operational 
observation. 

Total dedication. "The course of 
study is designed to take advantage 
of prior training and experience," 
says CDR Hammett. "By the time a 
person is accepted for Advanced 
Hospital Corpsman Technician 
School, he or she usually has sever- 
al years of experience and has often 
gone through specialized training in 
one or more of the medical disci- 
plines. All these skills are chan- 
neled into a program which enables 
the advanced hospital corpsman 
technician to provide health care in 
support of or in the absence of a 
physician." 

Hollywood's version of the hos- 
pital corpsman performing a dra- 
matic life-saving procedure aboard 
ship under adverse conditions is 
overdramatized for effect. Although 
the advanced hospital corpsman 
technician on independent duty 
must be able to meet emergency 
situations in a calm and confident 
manner, the everyday job of tending 
to the crew's health and welfare is 
far more demanding and requires 
total dedication. 

Medical technology and the tools 
of medical care have developed over 
the years but the concept of unself- 
ish concern and the Medical Depart- 
ment's tradition of humanitarian 
service remains unchanged. Many 
Navy hospital corpsmen have died 
carrying this tradition into battle. 

— Story and photos contributed by Lee W. 
Coleman. 



Volume 69, February 1978 



15 



Policy 

Instructions and Directives 



Nonnaval medical and dental care 

Under certain conditions, the Navy will bear the cost 
of medical and dental care that active-duty personnel 
obtain from non-Navy and non-federal sources. Active- 
duty personnel must seek care from a federal medical 
facility, if one is available; however, in emergencies — 
situations where the need for medical or dental atten- 
tion is such that required authority for such care cannot 
be obtained — care may be sought from civilian sources. 
Members who obtain emergency medical or dental care 
should immediately inform the medical officer or dental 
officer of the district where the care is rendered, who 
may then arrange for the patient's transfer to a federal 
medical treatment facility. 

Except in such emergency situations, the Navy will 
pay for care from non-federal sources only if such care 
is authorized in advance. Requests for authorization 
should be submitted by letter. 

Overseas, commanding officers may authorize care 
from other than U.S. naval sources. However, when 
ships are in NATO or SOFA ports, care shall first be 
sought from military facilities of the host country, if 
U.S. facilities are not available. 

Authorized medical care includes consultations, 
hospital care, surgery, nursing, medicine, laboratory 
and X-ray services, physical therapy, and eye examina- 
tions. Authorized dental care includes treatment to re- 
lieve pain and stop infection, operative and restorative 
services, prosthetic treatment to restore extensive loss 
of masticatory function or to replace anterior teeth for 
aesthetic reasons; repair of dental prosthesis; treat- 
ment rendered as an adjunct to medical or surgical 
care; and X-rays and drugs. Also authorized are refrac- 
tions of eyes {provided no prescription is in the health 
record) and repair or furnishing of spectacles (but not 
contact lenses). 

The Navy will not pay for care provided members 
continuously absent without authority during a period 
of treatment. However, should the member return to 
military control before the care is completed, payment 
will be made as though no unauthorized absence ex- 
isted. "Constructive" return to military control occurs 
when a naval activity informs the civilian facility — 
orally or in writing — that the Navy will accept responsi- 
bility for the patient's care. Return to military control is 
also effected when a member is arrested by civil author- 
ities at the Navy's request or for a civil offense and after 
the civil authorities notify the Navy that the member 



can be released to military custody. 

A Civilian Medical/Dental Care Statement (NAV- 
MED 6320/10) shall be forwarded to the approving offi- 
cer; the diagnosis shall be listed on the form, and if 
prior approval was not obtained, the circumstances 
which necessitated use of non-federal facilities shall be 
recorded. When the approving officer has received the 
required documents, he shall determine whether the 
bills are payable in whole or in part, or whether the 
claim should be disallowed. Normally, payment should 
be approved at rates generally prevailing within the 
area where the care was provided. 

Approving authorities shall process bills within 30 
days of their receipt. When approving officers already 
have information available from messages or other cor- 
respondence to support payment of the claim, the re- 
quirement for a NAVMED 6320/10 shall be waived and 
the claim approved for payment. Payment shall not be 
withheld to seek payment from health benefit plans or 
private insurance policies. 

The accounts of Navy and Marine Corps officers 
should be checked for subsistence. 

All commands should ensure that their personnel are 
aware of Navy policy on obtaining medical and dental 
care from civilian sources. If a service member should 
fail to comply with requirements, the Navy may deny 
responsibility for medical or dental care expenses. — 
BUMED Instruction 6320.32C of 7 Oct 1977. 

Smallpox immunization for dependents 

While the actual hazards of contracting smallpox are 
steadily diminishing, many countries enforce then- 
sovereign right to protect themselves against the intro- 
duction of this disease. Unvaccinated persons may be 
denied entry into a country, or may be subject to vacci- 
nation by force or to medical followup or isolation. Mili- 
tary dependents who contemplate travel overseas, in- 
cluding travel as tourists, should be made aware of 
local smallpox immunization requirements by their 
Medical Department representative. 

When smallpox vaccination is contraindicated for 
medical reasons, a dated statement to this effect, writ- 
ten on a physician's professional stationery and signed 
by a physician, must be attached to the patient's Inter- 
national Certificate of Vaccination (PHS-731). It is not 
sufficient merely to write "medically contraindicated" 
on the patient's immunization record.— BUMED Notice 
6230 of 11 Oct 1977. 



16 



U.S. Navy Medicine 



IMAVMED Newsmakers 




LCDR Kaires: Like no other 

The working uniform of LCDR 
Pamela Kaires (MC) is like that of 
no other Navy woman: The suit 
weighs 16 lb, the shoes weigh 80 lb, 
and the belt adds another 84 lb. 
There's a helmet, too: that weighs 
109 lb. But Dr. Kaires sees the uni- 
form as a thing of beauty which she 
earned the right to wear on her way 
to becoming the Navy's first woman 
submarine/diving medical officer. 
During an eight-week course at the 
Navy School of Diving and Salvage, 
Dr. Kaires used the traditional 
Mark V mixed-gas diving outfit for 
dives to depths of 300 feet in order 
to understand diving problems and 
the psychological effects of diving. 
When she completes submarine 
training at New London, Conn., she 
looks forward to participating in un- 
dersea research projects and sup- 
porting large salvage operations. 

LCDR Johnnie Turner (DC), pros- 
thetic officer with the 2d Dental 
Company, Force Troops/2d Force 
Service Support Group, Camp Le- 
jeune, N.C., commissioned a doctor 
of dental surgery last year — his 
wife, Carol. The new LT Turner had 
been in private practice for two 

Panhandle Mountain Boys 



Turners: Sharing a career 

years. Why did she decide to go 
Navy? "I wanted to share a Navy 
career with my husband," she says. 

Second prize in the 1977 All Navy 
Talent Contest went to a tub-thump- 
ing, banjo-picking band of hospital 
corpsmen known as "The Panhan- 
dle Mountain Boys." All from Naval 
Aerospace and Regional Medical 
Center, Pensacola, the musical five 
— HM3 "Mr. Bones" Covington, 
HM3 "Junior" Barnes, HM2 "Un- 
cle Ed" Rowntree, HM2 "Honky" 
Janke, and HN "Swampstick" Pea- 
cock — also starred in a locally tele- 
vised segment of the National Jerry 
Lewis Muscular Dystrophy Tele- 
thon. 





VADM Arentzen congratulates 
RADM Paulsen on his retirement 

On 27 Sept 1977, RADM 
Albert G. Paulsen retired after 
more than 32 years of active 
and inactive service in the 
Dental Corps of the U.S. Naval 
Reserve. In his parting re- 
marks, he captured the es- 
sence of a lifetime in Navy 
dentistry: 

Many forward-looking changes 
have taken place in the practice of 
dentistry in the Dental Corps of 
the Navy's Medical Department 
since my first commission early in 
1 941 , and others are certai n to fol- 
low. To have been a witness to 
these changes and to be per- 
mitted to participate in them— to 
number among one's friends so 
many who have been foremost in 
bringing these changes about — 
has indeed been a rare privilege. 

Few things in life have meant 
more to me than the profession of 
which I have been a member and 
being a part of the great United 
States Navy! Through both I have 
been able to be of service to my 
fellow man, to care for my family, 
and to provide for my old age 
(should that ever overtake me). 
Over 30 years is all too brief a 
time in which to repay the debt I 
owe to the dental profession. 

The years spent in active 
practice, in teaching, and in the 
Navy have been years of absorb- 
ing interest, crowded with oppor- 
tunities for service, happy asso- 
ciations with co-workers, and in- 
spiring contacts with appreciative 
patients. To these interests 
should be added the confident be- 
lief that all that has gone before in 
the advancement of dentistry is 
but a "stepping stone to higher 
things"— that in the life of a pro- 
fession, as in life itself, "the best 
is yet to be. " 



17 



Professional 



The Anniversary Reaction: An Easily 
Overlooked Clinical Phenomenon 



CDR Jesse O. Cavenar, MC, USNR-R 
Allan A. Maltbie, M.D. 
Elliott B. Hammett, M.D. 



Recognition and appropriate management of an 
anniversary reaction can be of enormous value in the 
care of patients with otherwise perplexing clinical 
presentations, An anniversary reaction may be de- 
fined as a psychological or physiological event which 
occurs at a specific time which is significant to the 
patient, even though he is often unaware of its signi- 
ficance. The period may be the anniversary of a pre- 
vious loss or trauma to the patient himself or to a 
person with whom the patient is closely identified. 
An anniversary reaction may simply occur annually 
at a specific anniversary date; or the episode may 
represent a summation of various factors, including 
multiple losses, where the specific age or situation of 
the patient— or of another individual with whom the 
patient identifies— approximates the time and 
circumstances of a past traumatic experience. The 
anniversary reaction itself is viewed as the patient's 
unconscious struggle to master or control the previ- 
ous trauma by reliving the experience through the 
formation of symptoms, dreams, or overt behavior. 

Freud U) first described anniversary reaction in 
1895. In his report of Elizabeth Von R. , Freud noted 
that his patient experienced the exact remembrance 
of previous traumas, with expression of associated 
feelings occurring on the anniversary of the events. 
In Beyond the Pleasure Principle (2), Freud devel- 
oped the concept of repetition compulsion, charac- 



From the Psychiatry Service, Veterans Administration Hos- 
pital, 508 Fulton St., Durham, N.C. 27705. 

Dr. Cavenar is chief of the Durham VA Hospital Psychiatry 
Service, and Drs. Maltbie and Hammett are staff psychiatrists 
there. The authors also hold academic positions in the Duke Uni- 
versity Department of Psychiatry, where Dr. Cavenar is associate 
professor and Drs. Maltbie and Hammett are assistant profes- 
sors. 



terized by an individual's recurrent efforts to master 
early psychologically traumatic events not mastered 
at the time they occurred. Perhaps the most striking 
clinical example of this process is the anniversary re- 
action. 

Pollock (3) has written extensively on the subject 
of anniversary reactions and has demonstrated that 
these reactions are due to inadequate grief or mourn- 
ing over a personal loss or disappointment. He de- 
scribes patients in whom symptoms occur at a spe- 
cific hour of the day, a specific day of the week, or on 
certain holidays during the year. 

Hilgard and Newman (4) reported on patients 
whose depression or psychotic reactions were pre- 
cipitated on the anniversary of sibling deaths during 
childhood. In another report (5), Hilgard noted that 
an adult patient may develop an anniversary reaction 
when he reaches the age at which his parent died. 
And in a third paper (6) he pointed out that a patient 
may experience a reaction when his child reaches the 
age at which a trauma occurred in the patient's child- 
hood. 

Engel (7), an internist and psychoanalyst, recently 
published a fascinating personal account of anniver- 
sary reaction. He kept a carefully dictated record of 
his experiences and dreams, and noted multiple ex- 
amples of phenomena involving the anniversary of 
the death of his identical twin brother as well as the 
experience of living through the age when his father 
died. Both brother and father died from myocardial 
infarctions. Engel's reactions were both psychologi- 
cal and somatic, and included his own myocardial 
infarction. 

Weiss et al {8) described patients in whom hyper- 
tensive crisis, myocardial infarction, and irritable 
bowel syndrome occurred as anniversary reactions. 
Other illnesses, such as ulcerative colitis (9), head- 



18 



U.S. Navy Medicine 



ache (10), rheumatoid arthritis (11), and various 
dermatologic reactions (12), have been observed as 
anniversary phenomena. Cavenar et al (13) have ob- 
served headache, back pain, and peptic ulcer disease 
presenting as physical complaints attributed to anni- 
versary reactions. 

In this paper we hope to alert health care person- 
nel to this commonly occurring clinical phenomenon. 
The following patient reports are illustrative. 

PATIENT REPORTS 

Patient 1. This thin, 44-year-old married man entered the hos- 
pital on the medical service in September 1975 because of peptic 
ulcer pain. He had first experienced ulcer pain in 1954 while 
serving on active military duty; his pain had been controlled by 
antacids until this episode. 

Symptoms on admission to the hospital included intractable 
pain, hematemesis, and partial obstruction. A Billroth II pylorec- 
tomy was done. His postoperative course was stormy, for reasons 
which were not medically apparent, and he required intravenous 
fluids and gastric suction for 31 days. 

After he was discharged from the hospital the patient did not 
do well. He experienced a progressive loss of energy until he 
could not work. He reported vomiting and sweating several times 
a week, symptoms his physician believed represented a minor 
dumping syndrome. 

Because of these complaints, the patient was admitted to the 
gastroenterology service of the hospital in August 1976. The 
results of a complete medical evaluation, including endoscopy, 
oral cholecystogram, proctoscopy, upper and lower gastrointesti- 
nal series, and extensive blood work, were normal except for 
evidence of the previous surgery. There were no findings to ac- 
count for the patient's symptoms, and medically he was con- 
sidered to be able to work. Because of the absence of any 
pathologic condition, psychiatric evaluation of the patient was re- 
quested. 

On mental status examination the patient was oriented to time, 
place , and person ; he was not psychotic and did not appear clini- 
cally depressed. A rigid character structure was present and 
denial was a major defense mechanism. 

Review of the patient's history revealed he had been raised on 
a farm as the third of eight children. He said he and his father 
had been ' 'very close," and he reported a warm, caring relation- 
ship with his mother. When the patient was 12 years old, the 
father died on 18 October while undergoing surgery for ' 'stomach 
problems." The father was 43 at the time of his death. (The pa- 
tient's own surgery, necessitated by an exacerbation of ulcer 
pain, was performed in late September of his 43rd year.) 

The patient had been unable to attend his father's funeral be- 
cause he felt he could not stand the anguish and strain. But after 
the funeral he went alone to the cemetery, where he was able to 
grieve without other people being present. The patient then quit 
school and took over his father's job on the farm. 

The patient's loss of energy and his apathy toward life in 
general were felt to represent an anniversary response. He had 
reached the age at which his father had died and he himself ex- 
pected to die during his own surgery. He was able to verbalize 
this feeling on one occasion as he cried about his father's death; 
massive denial was then necessary to defend against other feel- 
ings. 



An intravenous sodium amytal interview was done, using the 
method reported by Cavenar et al (14), in an attempt to recover 
more of the patient's feelings. The patient did show sadness in 
talking about his father's death, but no additional affect could be 
mobilized. 

Because of the patient's rigidity and the effect hia father's 
death had upon his total personality structure, a favorable out- 
come could not be obtained. The patient was discharged to the 
care of his local physician. 

This report illustrates the anniversary reaction in which the pa- 
tient develops symptoms upon reaching the age at which a parent 
died. This is a very common clinical presentation of an anniver- 
sary reaction; the reaction may be expressed as a physical prob- 
lem or may be a psychogenic disturbance such as depression or 
psychosis. 

Patient 2. This 37-year-old, married, blue collar worker was 
seen in psychiatric consultation on referral from his family physi- 
cian. The patient reported a two- week history of increasing 
sadness, depressed moods, crying spells, anorexia, inability to 
sleep at night, and suicidal ideation. 

On mental status examination, the patient was a coherent, 
logical man who was not psychotic. He cried readily, admitted 
depressive symptoms, and expressed fears he might commit 
suicide. The previous evening, while walking around his prop- 
erty, he had entertained fantasies of walking into a pond; these 
thoughts frightened him to the point that he sought medical help. 

The patient was a religious man who had two children and re- 
ported that his marriage was excellent. He had held a responsible 
position with a manufacturing company for 15 years and reported 
no difficulty. Neither the patient nor his wife could account for his 
depression, so in an attempt to ascertain its cause, he was en- 
couraged to talk about any thoughts which occurred to him. 

He began talking about farm crops in the area and the need for 
rain. He casually remarked that the corn was now "about as 
high" as it was last year when his first cousin, to whom he was 
close, committed suicide. On further questioning, the patient 
revealed that the cousin had died by suicide exactly one year ago 
that week. The patient had not mourned at the time of the 
cousin's death, and was experiencing an anniversary reaction 
depression to the loss. 

Later he was seen in psychotherapy for two hours, during 
which time he focused on his feeling of loss over the death and his 
anger at the cousin for committing suicide. The patient's symp- 
toms resolved and he was referred back to his family physician. 

This report illustrates an anniversary reaction in which the 
dynamic issues were readily apparent and the problem was re- 
solved after several hours of focused, insight-oriented psycho- 
therapy. The prognosis for this patient is excellent. 

Patient 3. This thin, 56-year-old, married factory worker was 
admitted to the psychiatry service in November 1976 because of 
depression, ' ' drop attacks, ' ' and the feeling that he was unable to 
work. For four months, he had experienced increasing sadness, 
crying spells, anorexia, difficulty sleeping, and suicidal ideation. 

On mental status examination, he was nervous and depressed, 
but not psychotic. He cried readily and admitted to depressive 
symptoms and suicidal ideation. 

The patient said his mother had developed a malignancy while 
he was living with her; to her distress, he later moved out and 
deserted her. Her illness progressed and she died two days be- 
fore Thanksgiving 19 years ago. The funeral was held on Thanks- 
giving Day. 



Volume 69, February 1978 



19 



The patient had experienced drop attacks and dizziness for 
months prior to entering the hospital. He also reported that his 
father began to have drop attacks and small strokes in his "late 
fifties." Concerned because he, too, was now in his late fifties, 
the patient said he anticipated having a stroke and dying soon. 

The patient was encouraged to talk at length about his guilt 
over deserting his mother. As he became able to verbalize his 
concerns and as Thanksgiving Day passed without incident, his 
depression cleared. His drop attacks were determined to be 
caused by bis medication; when the drug was discontinued, the 
patient's dizziness and drop attacks stopped. 

This patient experienced anniversary responses to two differ- 
ent events: he had reached the age at which his father died, and 
also it was the time of year that his mother died. When he was 
able to verbalize guilt and anger over these losses, his symptoms 
unproved. His prognosis was good, 

Patient 4. This 23-year-old woman, married to a doctoral candi- 
date, entered psychoanalysis because of multiple phobias, free- 
floating anxiety, and low self-esteem. 

Despite her superior intellect, the patient had been unable to 
complete one remaining course needed to obtain her baccalaure- 
ate degree. Neither of her parents had been able to complete 
college in their native land because of the outbreak of World War 
II, although both had been enrolled at the most respected univer- 
sity in their country when the war started. The mother's life had 
been spared in a concentration camp because of her superior in- 
telligence. Notwithstanding the adversities her parents had ex- 
perienced, the patient had angry feelings about and resented 
both parents because of their lack of education. Her father died of 
malignancy when the patient was 18, and she had felt some guilt 
about not arriving home while he was still conscious. 

Psychoanalysis showed slow but steady progress, with many 
issues becoming conscious and being worked through. In the 
third year of treatment, a dream was brought which seemed out 
of context with the general flow of material at the moment. The 
dream concerned yellow roses and crowds of people; the patient's 
thoughts were of flowers, funerals, and crowds attending 
funerals. Suddenly, she realized it was five years ago that day 
that her father had died. This realization led to an outpouring of 
grief during the hour of therapy, and a grief reaction over the 
next several weeks. The patient had not been able to grieve at the 
time of her father's death, but had instead been in a rage at her 
mother. Additional material over several weeks concerned many 
feelings— both positive and negative— about her father. 

This patient's story shows that even when memories are not 
consciously available — are totally out of awareness — they exert a 
strong force unconsciously. The patient's anniversary response 
was such a force, even though she had no conscious recognition 
that it was the date of her father's death. 

Patient 5. This 57-year-old married professional was admitted 
to the psychiatry service because of dependence on narcotics, 
barbiturates, and minor tranquilizers. 

The patient was dirty and disheveled and had slow, slurred 
speech. On mental status examination, he appeared moderately 
depressed, but denied depressive symptoms. No psychosis was 
apparent, but he seemed to have an organic brain syndrome 
secondary to the drugs he had taken. 

His history disclosed that he had graduated third in his class in 
professional school and had been a member of professional 
honorary societies. He had entered private practice of his profes- 
sion and had been quite successful until he began to drink heav- 



ily; he then gradually substituted drugs for alcohol. 

As a child, this patient witnessed the accidental death of his 
father. The father was changing a flat tire on the family car while 
the patient was sitting in the back seat. The car was struck from 
the rear by a car driven by an intoxicated youth. The father's legs 
and pelvis were crushed and he died within hours. 

The father had been a professional man and the patient had 
followed the same profession, beginning to drink and use drugs 
when he reached the age at which his father had been killed. The 
patient reported he injected drugs into his legs and buttocks, 
simulating the injuries his father sustained in the accident. 

This report illustrates the onset of an anniversary reaction in a 
patient who has reached the age at which a significant person 
died. This patient's prognosis is very poor because of the pro- 
found influence this trauma has had upon his entire personality 
structure, his total inability to verbalize his feelings, and his 
impulsive addictive use of drugs and alcohol, 

DISCUSSION 

Pollock (3) notes that it is necessary in any consid- 
eration of anniversary reactions to carefully examine 
the past life of the patient, paying particular atten- 
tion to previous events, conflicts, and losses involv- 
ing significant individuals. The anniversary reaction 
may be considered as simply a releaser of repressed 
anxiety-provoking material. The reaction, response, 
or symptom may be transitory, and adaptation may 
occur, with reestablishment of a symptom-free 
psychologic equilibrium. On the other hand, the re- 
action may result in psychological regression and 
establishment of persistent pathological defenses 
leading to chronic disability, as in patients 1 and 5. 

The primary dynamic common to all anniversary 
reactions is inadequate or incomplete mourning of a 
previous loss. This loss may be recent or may have 
occurred many years earlier. In the treatment of 
anniversary reactions, the patient's guilt and uncon- 
scious angry feelings directed toward the lost person 
must be made conscious. Once the anger is verbal- 
ized and integrated psychologically, the normal grief 
process will proceed and the anniversary symptoms 
abate. This is what happened in patients 2,3, and 4. 

The anniversary reaction may either present as a 
condition in its own right or may serve as a recurrent 
anxiety trigger which reactivates a preexisting 
psychological or medical condition. Certainly in any 
patient with an unexplained depression, psychosis, 
psychophysiologic symptom complex, or recurring 
psychosomatic illness with a set pattern or "coinci- 
dental" features mimicking those of a lost loved one, 
the possibility of anniversary reaction should be con- 
sidered. It is essential that these unresolved grief re- 
actions be accurately diagnosed, since they are often 
easily treated by psychotherapy with excellent re- 
sults. 



20 



U.S. Navy Medicine 



REFERENCES 

1. Freud S: Studies onHysteria, standard edition of complete 
psychological works, vol 2. London: Hogarth Press, 1955. 

2. Freud S: Beyond the Pleasure Principle, standard edition 
of complete psychological works, vol 23. London: Hogarth Press, 
1955. 

3. Pollock GH: Temporal anniversary manifestations: hour, 
day, holiday. Psychoanal Quart 40:123, 1971. 

4. Hilgard JR, Newman MF: Anniversaries in mental illness. 
Psychiatry 22:113-121, 1949. 

5. Hilgard JR: Anniversary reactions in parents precipitated 
by children. Psychiatry 26:73-80, 1953. 

6. Hilgard JR: Depressive and psychotic states as anniver- 
saries to sibling death in childhood. Int Psychiatry Clin 6:197-211, 
1969. 

7. Engel GL: The death of a twin: mourning and anniversary 
reactions. Fragments of ten years of self-analysis. Int J Psycho- 



anal 56:23, 1975. 

8. Weiss E, Olin B, Rollin HR, Fischer HK, Bepler CR: 
Emotional factors in coronary occlusion. Arch Intern Med 99:628- 
641, 1957. 

9. Bressler B: Ulcerative colitis as an anniversary symptom. 
Psychoanal Rev 43:381-387, 1956. 

10. Griffin M: Some psychiatric aspects of migraine. Proc of 
Staff Meetings of Mayo Clinic 28:694-697, 1953. 

11. Ludwig AD: Rheumatoid arthritis, in Wittkower ED, 
Cleghom RA (eds): Psychosomatic Medicine. Philadelphia: J.B. 
Lippincott Co., 1954. 

12. Macalpine I: Psychosomatic symptom formation. Lancet 
1<6702):278, 9 Feb 1952. 

13. Cavenar JO Jr, Nash JL, Maltbie AA: Anniversary reac- 
tions presenting as physical complaints. Dis Nerv Sys, to be pub- 
lished. 

14. Cavenar JO Jr, Nash JL: Narcoanalysis: the forgotten 
diagnostic aid. Milit Med 142:553-555, 1977. 



Preventive Medicine 



Lead Poisoning 



Lead is a necessary constituent of 
many products used in the Navy — 
storage batteries, glass, radiators, 
conduits and pipes, paints, glazes, 
solder, printing type metals, plas- 
tics, bearings, and chemical tank 
linings are some examples. Unfor- 
tunately, during processing lead 
can accumulate in workers' bodies, 
sometimes resulting in lead poison- 
ing. 

Lead can interfere with the pro- 
duction of heme and thereby alter 
the urinary or blood concentration 
of enzymes and intermediates in 
heme synthesis or the derivatives. 
Thus, lead poisoning can lead to ac- 
cumulation of non-heme iron and 
protoporphyrin in red blood cells, 
and an increased proportion of im- 
mature red cells in the blood. 
Anemia from lead poisoning is asso- 
ciated with a reduced red cell life 
span and other problems in periph- 
eral blood. Symptoms of this anemia 
include irritability, fatigue, pallor, 
and sallow complexion. Gastrointes- 
tinal symptoms of lead poisoning 
include intestinal colic, nausea (of- 
ten without vomiting), constipation, 



and sometimes diarrhea. Head- 
aches usually occur before or at the 
onset of colic. 

Peripheral and central nervous 
system effects occur in severe poi- 
soning. Nervous system involve- 
ment consists of considerable loss of 
motor function but little loss of sen- 
sory function. Extensor muscles of 
hands and feet are often involved. 

There are many ways workers can 
be exposed to lead hazards. Weld- 
ing, cutting, brazing and soldering 
of lead-bearing alloys and com- 
pounds or metals coated with lead 
can produce lead fumes and dust in 
significant concentrations. People 
may be exposed in machine and 
automobile repair shops when lead- 
bearing gasoline is burned in en- 
gines and lead is subsequently re- 
leased into the environment through 
engine exhaust systems. 

Although ingestion of lead may 
not be common in the Navy, the 
possibility cannot be overlooked. 
Ingestion occurs because of poor 
personal hygiene, or results from 
use of improperly fired lead-glazed 
containers. 



Lead exposure and serious illness 
can be avoided if safety precautions 
are taken and workers are informed 
about the consequences of lead ex- 
posure. Local exhaust ventilation 
and collection systems should be 
used and properly maintained to 
prevent lead dust and fumes from 
accumulating in the work environ- 
ment. Where local exhaust ventila- 
tion is not available, a NIOSH- 
approved respirator should be used 
(NS-00-099-8939). 

Eating, drinking, or smoking in 
work areas should be avoided. Alco- 
holic beverages should also be 
avoided because alcohol tends to 
increase lead absorption potential. 

Good personal hygiene habits — 
wearing clean clothing, brushing 
teeth regularly, and bathing after 
leaving work — will help remove 
lead dust from the body. 

Medical Department representa- 
tives should instruct personnel who 
work in hazardous areas to report 
any illness which could be related to 
lead poisoning. 

—Pacific Health Bulletin, No. 98, June 

1977. 



Volume 69, February 1978 



2] 



Tooth-Supported Full Denture Prostheses: 
Review of the Literature and Patient Report 



LT Gary E. Jeffers, DC, USN 



While alveolar ridge resorption following multiple 
extractions has always been a prime concern for oral 
surgeons and prosthodontists, increased longevity of 
patients has made it an increasingly important factor 
in complete denture construction. Many dentists 
treat elderly patients who have worn several sets of 
dentures— each less satisfactory than the previous 
set— since being rendered edentulous at an early 
age. These patients find it difficult to accept that 
continuous residual ridge resorption has made them 
"dental cripples." Other patients, who have man- 
aged to retain their teeth until an advanced age, find 
they are unable to cope with dentures either physio- 
logically or psychologically. 

Another concern in denture construction is to pro- 
vide additional retentive and stabilizing forces to 
achieve adequate function and comfort for denture 
wearers. 

The tooth-supported prosthesis— or overdenture, 
as it is often known*— can help the prosthodontist 
prevent further bony destruction, while assuring 
adequate function and patient comfort. This pros- 
thesis is basically a partial or complete denture fabri- 
cated over retained teeth or roots which may or may 
not have been prepared to receive the prosthesis (i). 

This paper reviews the literature regarding use of 
the tooth-supported full denture prosthesis and 
offers a detailed account of one patient's treatment. 

REVIEW OF LITERATURE 

While the concept of overdenture s is not new, it 
has in recent years gained the attention of increasing 
numbers of dental practitioners. As a result, over- 
dentures are today the preferred modality of treat- 
ment for many more patients. 



LT Jeffers is a staff member in the Branch Dental Clinic, U.S. 
Naval Activities, London, FPO New York 09510. This paper was 
written while he was a dental general practice resident at the 
Naval Regional Medical Center, Portsmouth, Va. 

*This device has also been referred to as an overlaying den- 
ture, telescopic denture, or hybrid prosthesis. 



The earliest reference to the overdenture concept 
is that of Burkes in 1861, who reported the proceed- 
ings of the American Dental Convention in New 
Haven, Conn. At that meeting Drs. Butler, Roberts, 
Atkinson, Sutton, and Hayes presented a symposium 
entitled, "Surgical Preparation of the Mouth for 
Artificial Dentures: Should the Roots of Broken and 
Decayed Teeth Always be Removed?" Hayes de- 
scribed a patient in whom a maxillary denture, 
placed over two roots, was after 12 years still service- 
able and comfortable (2). 

In 1945, Black (2) used this technique to provide 
complete dentures for a 14-year-old girl with con- 
genital absence of permanent dentition. Black made 
use of four maxillary and four mandibular teeth in 
fitting modified crowns to the molars. Twenty-seven 
years later, the deciduous mandibular molars were 
still intact supporting a lower denture. 

During World War II, military dentists often used 
overdentures to treat inadequate and mutilated den- 
titions (2). For example, Dental Digest of July 1948 
carries a report of a patient treated with a denture 
placed over two retained molars. 

Rehn (3), in 1952, was one of the first to advocate 
the overdenture principle in retaining as little as a 
single "front" tooth to support a prosthetic device. 
In 1958, Miller (4), discussing the findings of a 
ten-year study, reported that when a few isolated 
teeth were retained to support a complete denture, 
the "weak" teeth regained their healthy status. 
Later, Morrow and his colleagues {5) advocated 
using gold copings over retained teeth and concomi- 
tant use of metal castings within the denture base. 
Lord and Teel (6"), in 1969, reported success after 
using overdentures in their practice for seven years. 

Since 1969, various methods of using natural teeth 
to support and retain an overlay prosthesis have 
been described (7-10). Brill (7) recommended 
reducing the clinical crown height to just over 1 mm 
to improve the crown-root ratio, and advocated the 
use of stud attachments. Dolder (8), on the other 
hand, suggested that a rigid bar be used to join gold 
copings on isolated teeth. 



22 



U.S. Navy Medicine 



ADVANTAGES OF OVERDENTURES 

In recent years, Dodge (11) and other researchers 
12-12), through knowledge gained by clinical 
experience, have been able to enumerate a number 
of advantages that may make overdentures prefer- 
able to conventional prosthetic devices: 

Stability. Vertical, anterior-posterior, and lateral 
stability is enhanced because of the presence of 
abutment teeth and the preservation of alveolar 
bone. Thus the stability of overdentures is compara- 
ble to stability obtained with fixed or removable par- 
tial dentures (10-13). 

Retention. The alveolar bone, which normally 
"melts away" when teeth are extracted, remains 
relatively intact so long as a root and associated 
periodontal structures are maintained in a healthy 
state within the bone [14) . Tallgren {IS) reports that 
the average linear bone loss of 6.6 mm in the man- 
dibular anterior ridge is as much as four times 
greater than bone loss in the maxillary arch. 

Both Goerig (16) and Kelly (17) have reported a 
number of indications for use of overdentures in the 
maxilla. They found distinct or total bone loss in the 
maxillary anterior region in patients wearing a com- 
plete maxillary denture opposing natural dentition in 
the lower ridge, even in patients wearing a mandibu- 
lar distal extension partial denture. Also, a seven- 
year study concluded in 1967 showed that, over a 
given period of time, the anterior part of the mandi- 
ble lost ten times more bone under complete den- 
tures than when overdentures were used (18). 

Proprioception. Proprioceptors appear to lie 
almost entirely within the tissues of the periodon- 
tium to provide an awareness of jaw-space relation- 
ships (11) and to protect against accidental traumatic 
overclosure of the jaws. When teeth and their asso- 
ciated periodontal structures are removed, this sen- 
sitivity is reduced or lost. Manly (19) and associates 
demonstrated this lack of perception in patients with 
complete dentures. Kruger and Michael (20) placed 
microelectrodes in the brains of decerebrated cats 
and then used manual pressure to stimulate teeth 
and other areas of the oral cavity. They found the 
canine teeth to be more richly endowed with neurons 
than any other teeth. In another study, Jerge (21) 
demonstrated that the activity of specific muscles at- 
tached to the mandible is directed by specific recep- 
tors in specific teeth. 

Pfaffman (22), a prime researcher in the area of 
proprioception, showed that removal of coronal and 
pulpal tissues produced no change in the elicited re- 
sponse. Likewise— and this is probably Pfaffmann's 



most significant finding— if all but a small portion of 
a root were removed, only extremely light pressure 
on the remaining portion was needed to evoke a re- 
sponse. 

Loiselle and his associates (18) found that eccen- 
tric contacts are easily memorized when the patient 
has a definite end point, as is the case with the "re- 
duced tooth." Loiselle refers to this mechanism as 
"reinforcement awards." This ability to remember 
contacts is physiologically limited once the last tooth 
has been extracted. Loiselle therefore concludes that 
the reduction of the crowns of at least two mandibu- 
lar canine teeth and use of overdentures will help 
preserve proprioceptive inputs to the neural centers . 

Vertical dimension. When teeth are retained to 
support overdentures, the height of vertical dimen- 
sion, if determined to be acceptable, can be main- 
tained with a great degree of accuracy. However, 
even retaining only a few roots aids considerably in 
tooth placement. Furthermore, retention of a few 
teeth adds stability to the recording bases (2) . 

Comfort. Ideally, the denture should be supported 
by abutment teeth with the remaining teeth acting as 
stress receivers, thus relieving the residual ridge of 
much of the occlusal load. Since the denture is sup- 
ported primarily by the abutment teeth in most pa- 
tients, the soft tissues of the alveolar ridge are 
spared much abuse. The patient with overdentures is 
therefore much more comfortable than the patient 
who wears complete dentures (12). 

Lip and face support. With the retention of natural 
dentition beneath the overdenture and maintenance 
of a more natural vertical dimension of occlusion, lip 
and facial structure support can more readily be 
maintained and settling is minimized. 

Simple construction. The technique used to create 
overdentures is basically the same as the method 
used to fabricate complete dentures. No special 
training is needed to enable dentists or technicians 
to prepare overdenture prostheses. 

Patient acceptance. Patient acceptance of over- 
dentures is excellent. Patients with overdentures 
gain a psychological advantage from knowing they 
still have their own teeth and need not go through 
the trauma of being rendered totally edentulous. 
Loss of all teeth appears to be more traumatic in 
older patients than in younger ones. Also, the pa- 
tient's masticatory performance is enhanced with 
overdentures as a result of the excellent vertical 
stability; many wearers report that with their new 
prosthesis they can eat anything (23). 

Ease in cleaning. With overdentures, all surfaces 
of isolated abutments are accessible for cleaning. 



Volume 69, February 1978 



23 



Conversion capabilities. Since tissue coverage and 
border extensions of overdentures are similar to 
complete dentures, the eventual loss of one or more 
of the retained "abutment" teeth does not preclude 
conversion to a conventional tissue-supported den- 
ture. Either spaces can be filled in or the denture can 
be relieved or rebased, if the need arises (2). 

INDICATIONS 

A tooth-supported denture should be the treat- 
ment of choice if the following criteria can be met: 

• Retention of one or more teeth or roots, to allow 
increased retention and stability of the denture. 

• The overdenture would be easier to construct than 
a conventional denture. 

• Preservation of the alveolar process would be en- 
hanced. 

Overdentures are also indicated for various con- 
genital and acquired defects of the dentition (24). 
Congenital defects which may benefit from this 
mode of treatment include cleft palate, oligodontia, 
and cleidocranial dysostosis; patients with Class HI 
malocclusion (such as a prognathic jaw) which can- 
not be corrected by orthodontic treatment or surgery 
may also benefit from overdentures. 

Acquired defects suitable for correction with over- 
dentures include traumatic malalignment following 
accidents or habitual misuse, and teeth which have 
become badly eroded, abraded or stained, or are un- 
sightly because of fluorosis. 

CONTRAINDICATIONS 

Overdentures are contraindicated if the teeth in 
question could adequately serve as abutments for 
conventional fixed or removable partial dentures. If 
after concentrated efforts to instruct him, the patient 
refuses or is incapable of maintaining adequate oral 
hygiene, overdentures are again contraindicated 
(25). In these patients, the suggested treatment is to 
extract all remaining teeth and replace them with 
complete dentures. 

Other contraindications are certain systemic com- 
plications which may preclude necessary clinical 
procedures, inadequate interarch distance (5), and 
the expense of extensive endodontic therapy which 
sometimes precedes overdenture construction. 

PREPARING ABUTMENT TEETH 

Careful selection of appropriate abutment teeth is 
of prime importance to the ultimate success or 



failure of the overdenture prosthesis. Teeth to be re- 
tained as overdenture abutments should be chosen 
on the basis of location, with special consideration 
given to any advantages the teeth may offer for den- 
ture stability and preservation of residual ridges 
(26). For example, edentulous areas in the anterior 
portion of both dental arches have been shown to be 
most subject to destruction; it would be therefore 
beneficial to retain healthy canines and premolars in 
these areas. As has been pointed out by some ob- 
servers (18,27,28), mandibular canines are most 
often retained because they are usually the last teeth 
lost and because without these teeth the mandibular 
denture would be more difficult to stabilize. When 
teeth are not available in both sides of the arch, an 
isolated tooth can be a successful abutment for an 
overdenture (27). 

Maintaining teeth in both arches can be of great 
assistance in establishing vertical dimension. Re- 
taining a canine and, whenever possible, a second 
rather than the first premolar provides for broader 
support. According to Morrow and his associates 
(10) , optimal distribution would be two canines and 
two molars in a single arch, providing excellent dis- 
tribution of vertical forces. This additional support is 
most important when the denture is opposed by 
natural dentition. 

Also, retained teeth should be maintained within a 
healthy periodontium. Deep periodontal pockets 
must be eliminated. An adequate zone of attached 
gingiva is a prerequisite for any tooth to be con- 
sidered as an overdenture abutment. 

In the absence of acceptable periodontal health, a 
number of corrective procedures can be accom- 
plished to regain suitable periodontal architecture. 
These preliminary mucogingival surgical procedures 
range from a simple gingivectomy to eliminate pock- 
ets, to the more heroic techniques of full-thickness or 
split-thickness apically positioned flaps and free gin- 
gival grafts to increase the band of attached gingiva. 

While some investigators (27) recommend the use 
of acrylic resin liners to provide additional support to 
ridge tissues following surgery, others believe that 
this practice is contraindicated. Immekus and 
Aramany (29) reported that resilient silicone denture 
liners may help retention; however, they also found 
that when placed over teeth, as is done with over- 
dentures, such liners can create an optimal environ- 
ment for bacterial growth with resultant destruction 
of the teeth and supporting soft tissues. 

Finally, tooth mobility in itself is not a contraindi- 
cation to using a tooth for an abutment. The deter- 
mining factor is the amount of remaining bony sup- 



24 



U.S. Navy Medicine 



port (27). The minimal acceptable level of bony sup- 
port is five millimeters. 

Frequently the dentist must greatly reduce crown 
height to derive a more favorable crown-to-root ratio 
and thereby minimize traumatic lateral forces upon 
teeth. The more the crown is reduced in such pa- 
tients, the better the prognosis; a tooth which may 
have exhibited mobility often becomes tight in its 
alveolus within a short time (24). 

In most instances where tooth reduction has been 
necessary, devitalization is routinely done. Only in 
rare instances when pulpal tissue is greatly receded 
can sufficient tooth reduction be accomplished with- 
out first completing endodontics (24). Either com- 
posite or amalgam restorations are acceptable for 
restoring the coronal portion of root canals (1,16). 

A matter of dispute among researchers evolves 
from the question of whether or not gold posts or 
copings should be incorporated into abutment teeth. 
The proponents of the coping technique are led by 
Brewer and Fenton (1,24), who believe that the gold 
coping is the treatment of choice. They contend that 
the patient seems to gain a tremendous psychologi- 
cal advantage when remaining tooth structures are 
covered with gold, as most patients do not like to 
have uncovered roots in their mouth. In addition, 
some immunity to decay is imparted by the metal 
cover. 

Since the remaining tooth structures often consist 
of only dentin and cementum, gold copings offer 
protection from such adverse effects as abrasion, at- 
trition, erosion, and trauma (4,13,12). Furthermore, 
the coping provides an optimum contour to the abut- 
ment teeth (30). When used, copings should be at 
least 1 mm thick. 

There have been many instances in which copings 
have worn thin and even been perforated by abrasion 
from denture resin. This problem has been 
countered somewhat successfully with chrome cobalt 
bearings (10) or denture-retained copings (4,31) 
placed over the tooth-borne copings. This practice is 
not widespread, the general feeling being that the 
resin of the overlay denture provides greater ease of 
adjustment and alteration of the denture base. 

Both short copings and longer, more tapered de- 
signs have been advocated. The concept of design 
and function was studied by Warren and Caputo 
(32) , who developed a method for photoelastic stress 
analysis to determine and compare the transfer of 
forces to the alveolar bone for various abutment de- 
signs. The researchers concluded that a direct rela- 
tionship exists between the stability and retention 
that each design provides and the amount of stress 



and torque transferred to supporting structures. If 
stress is the chief consideration, the short coping 
offers the best prognosis, the two researchers report. 
Lord and Teel (27) initially felt that gold copings 
should be placed over all retained teeth as soon as 
the tissues healed and the teeth stabilized. But more 
recently they have joined critics proposing that so 
long as sound tooth structure is present along with 
adequate oral hygiene, copings are unnecessary, as 
caries activity would be reduced to a minimum. 
When copings are not used, daily fluoride applica- 
tions to exposed tooth surfaces are advocated to pro- 
tect and prolong the integrity of retained teeth (24). 

USE OF ATTACHMENT DEVICES 

Occasionally, for retentive purposes, various types 
of attachment devices have been used in conjunction 
with conventional techniques already discussed. 
Dodge (11) believes that patients derive considerable 
benefit from the use of such attachments. 

A number of these attachment devices have been 
reported in the literature. Generally, they are of 
three main types: those on top of the retained root, 
those within the root structure itself, and those re- 
tained with a bar connecting the abutment teeth (31). 
Devices in the first two groups are basically a male- 
female type with one portion incorporated into the 
denture base and the other component placed within 
the retained tooth. 

For example, the Dalbo 604 attachment (Figure 1) , 
as described by Zamikoff (31), has a male component 




FIGURE 1. An attachment coping overdenture utilizing the 
Dalbo 604 attachment. The round portion (shown in box) per- 
mits movement without torquing the abutment teeth. 



Volume 69, February 1978 



25 



SPACER 



SLEEVE 




BAR 



FIGURE 2. Attachment coping over- 
denture with a Zest Anchor attachment 
device. 



FIGURE 3A. Attachment coping den- 
ture using Dolder bar. 



FIGURE 38. Cross-section of Dolder 
bar apparatus. A wire space is used only 
during processing to maintain a 1 mm 
space between bar and overlying sleeve 
in finished denture. 



fixed to the tooth and a female component within the 
denture base . The spherical shape of this attachment 
allows both anteroposterior and mesiodistal move- 
ment without torquing of the abutment tooth. The 
main disadvantage is increased cost and additional 
space required to insert the device. 

In another attachment device, the Zest Anchor 
(Figure 2), the female portion is cemented into a 
specially prepared cavity within the root (31). The 
male component, which extends from beneath the 
denture base and inserts into the root receptacle, is 
composed of nylon— a material that permits slight 
movements of the denture , eliminating the need for 
exact parallelism of the attachments during con- 
struction. The Zest Anchor overcomes the space 
problem encountered by the Dalbo 604 since its bulk 
is cemented within the root structure. 

Excellent retention is obtained from a number of 
bar-type appliances, such as the Dolder bar (8,31). 
This device (Figure 3A) consists of an egg-shaped 
bar which is attached to the copings of the abutment 
teeth and acts as a splint. The bar is overlayed with a 
sleeve contained within the denture base (Figure 3B) 
which snaps over the bar when the denture is in- 
serted. A 1 mm space between the bar and the over- 
lying sleeve in rest position allows some movement 
of the denture base in function; this movement does 
not interfere with retention and is important for pre- 
serving the abutment teeth. 

Other attachment devices described in the litera- 
ture include the Kurer Stud attachment in which 
posts with threaded shanks are placed in each root 



canal, which are then covered with a gold stud- type 
casting. Cast gold retentive clasps are incorporated 
into the denture base to engage the male portion of 
the stud attachment (Figure 4} when the denture is 
inserted. Crum and Loiselle (33), who described this 
device, emphasize that it offers the best support for a 
mandibular denture. They have termed their device 
a "physiological implant," contending that it 
enhances proprioceptive feedback mechanisms 
otherwise lost with the extraction of teeth. 

Dental practitioners should carefully examine the 
advantages and disadvantages of these and other 
attachment devices when considering their use. 
These attachments may place undesirable force on 
the abutment teeth. The additional time and expense 
involved should also be considered in determining 
whether or not their use would be desirable in treat- 
ing a particular patient. 

REPORT OF A PATIENT 

This 54-year-old Caucasian male, a railroad worker, presented 
for treatment in the Outpatient Clinic of the University of Pitts- 
burgh School of Dental Medicine. Pertinent medical findings in- 
cluded a problem of chronic alcohol abuse with associated anemia 
and malnutrition. Clinical and radiographic findings revealed a 
grossly neglected dentition with rampant dental caries, severe 
generalized periodontitis, and several missing teeth. Three of the 
remaining five maxillary teeth presented with large periapical 
radiolucent areas later diagnosed as acute or chronic alveolar 
abscesses. Oral hygiene was nonexistent. 

The patient wanted to keep his remaining teeth, but his poor 
periodontal condition did not offer a favorable prognosis. The 
mandibular canine teeth could be retained as abutments for an 



26 



U.S. Navy Medicine 



overlay denture. A treatment plan and appointment schedule 
were prepared as follows: 

Appointment I. The patient was required to attend a preven- 
tive dentistry film and lecture presentation, followed by extensive 
oral hygiene instruction. His remaining teeth were scaled for re- 
moval of gross calculus deposits. 

Appointment 2. Anticipating ultimate preparation of dentures 
utilizing the overdenture technique, the dental team gave careful 
consideration to recording the patient's vertical dimension. Ac- 
curate measurements were obtained after determining the 
vertical dimension of rest position and following closure to the 
desired vertical dimension of occlusion. 

Appointment 3. All remaining teeth except the two mandibular 
canines were extracted. 

Appointment 4. The patient returned with no significant im- 
provement in oral hygiene. Home care was again reinforced and 
the teeth were rescaled and polished. The patient was instructed 
to call the clinic for an appointment when he felt he was able to 
maintain adequate standards of dental care at home. 

Appointment 5. Two weeks later the patient was seen with 
marked improvement. Plaque scores were almost nil and gingival 
inflammation around the remaining teeth was significantly re- 
duced. Pocket depth had been reduced from 6 mm to approxi- 
mately 4 mm. 

Appointment 6. Gingivectomies were performed around teeth 
22 and 27 to eliminate pockets. Mobility had still not decreased. 

Appointments 7 and 8. Endodontics was done on both teeth, as 
it was necessary to significantly reduce crown height to provide a 
favorable crown-root ratio. 

Appointment 9. The abutment teeth were prepared as shown in 
Figure 5 (extensive labial reduction is necessary to allow ade- 
quate space for setting the overlying denture teeth). Next, two- 
thirds of the gutta-percha filling was removed to prepare the 
tooth to receive a post (Figure 6). A beveled finish line was pre- 
pared around the tooth. (Lateral grooves can be utilized within 
the post hole for added retention, if desired [31]}. Rubber-base 
copper tube impressions of each abutment tooth were then made. 

Appointment 10. Gold copings, prepared according to the 
method described by Welker and Kramer (30), were cemented in 
place. 

Appointment 11. Rubber-base final impressions were made. A 
stone cast was prepared for design of a small overlay framework 
of chrome cobalt. 

Appointment 12. The chrome cobalt framework (Figure 7) was 
placed and adjusted to assure adequate relief around the abut- 
ment copings. It was then incorporated into the acrylic denture 
base for further strength and support, and the overlay denture 
and opposing maxillary complete denture were constructed in the 
usual manner. 

At a subsequent visit, the overlay denture was given to the pa- 
tient. Oral hygiene and care of the prosthesis was reinforced. 

The patient was seen at periodic intervals for follow-up care 
and minor adjustments as necessary. After six months, he had 
experienced no adverse effects and radiographs at that time 
revealed no change in bony support. The patient's nutrition had 
significantly improved and he had sought assistance from an 
alcohol rehabilitation center. 



SUMMARY 

Overlay dentures, now being used in increased 
numbers, are providing satisfaction and lasting 



A 





B 




FIGURE 4. (A) Anchor post attachment within the root canal. 
(B) Male portion of stud attachment. (C) Stud attachment 
with retentive clasp as related within the denture. 





Vl 



FIGURE 5. Preparation of canine abutment teeth: (A) Tooth 
prior to preparation. Note its unfavorable crown-root ratio. 
<B) Tooth is sectioned 3 mm to 4 mm above crest of gingiva. 
(C) Extensive labial reduction is necessary to enable proper 
setting of overlying denture teeth. (D) Lingual reduction 
helps remove unfavorable undercuts. (E) Labial view showing 
proximal reduction. 




FIGURE 6. Tooth prepared for post and copings. 



Volume 69, February 1978 



27 




FIGURE 7. Round gold copings approximately 3 mm high 
with overlying chrome cobalt framework before incorporation 
into acrylic denture base. 

benefit to many individuals. Although not without 
problems, a majority of overdenture appliances have 
been used with great success. Careful patient selec- 
tion, preparation, and education can make the over- 
denture technique a valuable asset in the overall 
plan for preventive prosthodontics. 

This article is not intended to be all-encompassing 
with regard to overlay dentures. While I have at- 
tempted to present an overview of the topic as a 
means of stimulating thought, I realize that many 
other theories also exist. The dentist must be open- 
minded to derive full benefit from research into this 
important area of dentistry. 

REFERENCES 

1. Brewer AA, Fenton AH: The overdenture. Dent Clin North 
Am 17:723-746, 1973. 

2. Brewer AA, Morrow RM: Overdentures. St. Louis: C.V. 
Mosby Co., 1975, pp xi-xii, 12-14. 

3. Rehn H: Uber die Moglichkeit der Prothelischen. 
Auswartung eizelner Frontzahne. W.R. 6:115-117, 1952. 

4. Miller PA: Complete dentures supported by natural teeth. 
J Prosthet Dent 8:924-928, 1958. 

5. Morrow RM, Powell JM, Jameson WS, Jewson LG, Rudd 
KD: Tooth-supported complete dentures: description and clinical 
evaulation of a simplified technique. J Prosthet Dent 22:414-424, 
1969. 

6. Lord JL, Teel S: The overdenture. Dent Clin North Am 13: 
871-881, 1969. 

7. Brill N: Adaptation and the hybrid prosthesis. J Prosthet 
Dent 5:811, 1955. 

8. Dolder EJ: Bar joint mandibular denture. J Prosthet Dent 



11:689, 1961. 

9. Preiskel HW: Prefabricated attachments for complete 
overlay dentures. Br Dent J 123:161, 1961. 

10. Morrow RM, et al: Tooth supported complete dentures: an 
approach to preventive prosthodontics. J Prosthet Dent 21:513, 
1969. 

11. Dodge CA: Prevention of complete denture problems by 
use of "overdentures." J Prosthet Dent 30:403-411, 1973. 

12. Wayman B, Kuebker WA, Abrams H: Overdentures: a re- 
view of the literature and presentation of a technique. Gen Dent 
24:29-35, Mar-Apr 1976. 

13. Schweitzer JM, Schweitzer RD, Schweitzer J: The tele- 
scoped complete denture. J Prosthet Dent 26:357-372, 1971. 

14. Goska FA, Vandrak RF: Root submerged to preserve 
alveolar bone: a case report. Milit Med 137:446-447, 1972. 

15. Tallgren A: The continuing reduction of residual alveolar 
ridges in complete denture wearers: a mixed longitudinal study 
covering 25 years. J Prosthet Dent 27:120-132, 1972. 

16. Goerig AC: Immediate overdenture. JADA 88:356-359, 
1974. 

17. Kelly E: Changes caused by a mandibular removable 
partial denture opposing a maxillary complete denture. J 
Prosthet Dent 27:140, 1972. 

18. Loiselle RJ, Crum RJ, Rooney GE Jr, Stuever CH Jr: The 
physiologic basis for the overlay denture. J Prosthet Dent 28:4- 
12, 1972. 

19. Manly RS, Pfaffman C, Lathrop DD, Kaiser J: Oral sen- 
sory thresholds of persons with natural and artificial dentitions. J 
Dent Res 31:305-310, 1952. 

20. Kruger L, Michael F: A single neuron analysis of buccal 
cavity presentation in the sensory trigeminal complex of the cat. 
Arch Oral Biol 7:491-503, 1962. 

21. Jerge CR: Comments on the innervation of the teeth. Dent 
Clin North Am 9:117-127, 1965. 

22. Pfaffman C: Afferent impulses from the teeth due to pres- 
sure and noxious stimulation. J Physiol 97:207-219, 1939. 

23. Schabel R: The psychology of aging. J Prosthet Dent 
27:569-573, 1972. 

24. Brewer AA: The tooth-supported denture. J Prosthet Dent 
30:703-706, 1973. 

25. Guyer SE: Selectively retained vital roots for partial 
support of overdentures: apatient report. J Prosthet Dent 33:258- 
263, 1975. 

26. Maurer CR: Complete denture construction on an alveolar 
process containing endodontically treated roots. J Prosthet Dent 
30:756-758, 1973. 

27. Lord JL, Teel S: The overdenture: patient selection, use of 
copings, and follow-up evaluation. J Prosthet Dent 32:41-51, 
1974. 

28. Toth A: The distribution of the last four teeth in the oral 
cavity. Fogorv Sz 63:180-186, 1970. 

29. Immekus JE, Aram any M: Adverse effects of resilient 
denture liners for overlay dentures. J Prosthet Dent 32:178-181, 
1974. 

30. Welker WA, Kramer DC: Waxing tooth copings for over- 
dentures. J Prosthet Dent 32:668-671, 1974. 

31. Zamikoff II: Overdentures: theory and techniques. JADA 
86:853-857, 1973. 

32. Warren AB, Caputo AA; Load transfer to alveolar bone as 
influenced by abutment designs for tooth-supported dentures. J 
Prosthet Dent 33:137-148, 1975. 

33. Crum RJ, Loiselle RJ, Hayes CL: The stud attachment 
overlay denture and proprioception. JADA 82:583-586, 1971. 



28 



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OSGLI, 212 Washington St., Newark, N.J. 07102. 



2) Mail the complete VA form along with a fully en- 
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OSGLI. Upon approval of your application, OSGLI will 
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Within one year after 120 days have elapsed; 

1) Obtain VA Form 29-8714-2 (Application for Veter- 
ans Group Life Insurance — Veterans Separated More 
Than 120 Days) from any VA office or from OSGLI. 

2) Follow the same instructions given above, The 
basic difference between the two forms is inclusion of a 
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extended active duty after graduation, you should 
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will again become eligible for the VGLI five-year non- 
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I 'TO j B 



Volume 69, February 1978 



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